Bionic Ear

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Full Name *

Age *

Gender *

When was you hearing loss noticed?

Please inform us about the history of your illness:

Are there any accompanying diseases/symptoms?

Please state the medications you take on a regular basis (with doses)

Did you receive any treatments for this disease before?

I had an operation.

E.g. ear tube insertion, tympanoplasty, stapedectomy, cochlear implant surgery.

Pure tone audiometry

Tympanometry, acoustic reflex test

Brain stem response tests (ABR / BERA)

Otoacoustic emission

CT of temporal bone

MRI of temporal bone

Hemogram (Complete Blood Count) Report

Biochemistry Report

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