Ear Infection Risk Assessment Form
Please complete this form to help assess your risk for ear infections. Your responses will assist in evaluating your current symptoms and relevant risk factors.
Full Name
*
First Name
Last Name
Age
*
Have you experienced any of the following symptoms recently? (Select all that apply)
*
Ear pain or discomfort
Hearing loss or muffled hearing
Ear discharge or fluid leaking
Fever
Tugging or pulling at ear (especially in children)
Dizziness or balance problems
Other
How severe are your current symptoms?
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
How long have you been experiencing these symptoms?
*
Less than 24 hours
1-3 days
4-7 days
More than a week
Have you had an ear infection in the past 12 months?
*
Yes
No
Do you have any of the following risk factors? (Select all that apply)
Recent cold or upper respiratory infection
Allergies
Exposure to tobacco smoke
History of sinus infections
Frequent swimming or water exposure
Family history of ear infections
Other
Please indicate if you have any of the following medical conditions:
Immunodeficiency or weakened immune system
Chronic sinusitis
Cleft palate or craniofacial abnormalities
None of the above
Have you recently traveled or changed environments (e.g., air travel, altitude changes)?
Yes
No
If you are filling this form for a child, does the child attend daycare or preschool?
Yes
No
Not applicable
Please provide any additional information or concerns regarding your symptoms or risk factors.
Submit Assessment
Should be Empty: