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Get Asha Hearing Screening Form

RY—CIRCLE APPROPRIATE ANSWERS Do you think you have a hearing loss? Yes No Have hearing aid(s) ever been recommended for you? Yes No Is your hearing better in one ear? Yes No Have you ever had a sudden or rapid progression of hearing loss? Yes No Do you have ringing or noises in your ears? Yes No Do you consider dizziness to be a problem for you? Yes No Have you had recent drainage from your ear(s)? Yes No Yes No Have you received medical consultation for any of the above.

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