Acute Otitis Media Assessment
Please complete this form to assist in the clinical evaluation of suspected Acute Otitis Media.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Duration of Ear Symptoms (in days)
*
Which ear is affected?
*
Right
Left
Both
Please rate the severity of ear pain
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Current symptoms (select all that apply)
*
Fever
Ear discharge
Hearing loss
Irritability or fussiness (in children)
Recent upper respiratory infection (cold)
Other
Relevant Medical History
Ear Examination Findings
*
Rows
Normal
Abnormal
Tympanic membrane color
1
2
Tympanic membrane position (bulging/retracted)
3
4
Tympanic membrane mobility (on pneumatic otoscopy)
5
6
Presence of perforation
7
8
Presence of fluid
9
10
Submit Assessment
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