Patient Eustachian Tube Survey

Please select one of the answers to each question:

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Patient Name*
1. Pressure in the ears?*
No Problem
1
2
3 Moderate Problem
4
5
6 Severe Problem
7
2. Pain in the ears?*
No Problem
1
2
3 Moderate Problem
4
5
6 Severe Problem
7
3. A feeling that your ears are clogged or "under water"?*
No Problem
1
2
3 Moderate Problem
4
5
6 Severe Problem
7
4. Ear symptoms when you have a cold or sinusitis?*
No Problem
1
2
3 Moderate Problem
4
5
6 Severe Problem
7
5. Crackling or popping sounds in the ears?*
No Problem
1
2
3 Moderate Problem
4
5
6 Severe Problem
7
6. Ringing in the ears?*
No Problem
1
2
3 Moderate Problem
4
5
6 Severe Problem
7
7. A feeling that your hearing is muffled?*
No Problem
1
2
3 Moderate Problem
4
5
6 Severe Problem
7

New Patient Form

Before your first visit, please click the button to complete our New Patient Form

Northwest Sydney Clinic

Suite A12, Lvl 1, Westpac Building 24 Lexington Drive Bella Vista NSW 2153

02 8882 9477
02 8824 8414
reception@hillsent.com.au
Mon-Thurs: 8:30am - 3:30pm
Fri: 8:30am - 3:00pm
For bookings
bookings@hillsent.com.au

Lower North Shore Clinic

Suite 114b, Lvl 1, Ascent Building
40 Yeo Street
Neutral Bay NSW 2089

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