Eustachian Tube Dysfunction Assessment Form
Use this form to capture symptoms, triggers, and related history for an Eustachian Tube Dysfunction Assessment Form.
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
*
Phone
Email
Symptom Assessment
Ear fullness or pressure
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Ear pain
1
2
3
4
5
Popping or clicking in the ears
Never
1
2
3
4
Very often
5
1 is Never, 5 is Very often
Muffled hearing
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Balance or dizziness
None
Mild
Moderate
Severe
Other
Trigger and History
Likely triggers or recent context
*
Recent cold
Allergies
Sinus congestion
Recent ear infection
Recent air travel
High altitude exposure
Scuba diving or water pressure changes
Sudden pressure change (e.g., driving through mountains)
Other
Notes or additional relevant symptoms
Submit
Should be Empty: