* Dr Wilden - Specialist for Inner Ear Disease

Doctor Consultation
at NO COST
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Dear Patient,
One simple way to an individual, free informative consultation by phone consists in having as much information available as possible about the corresponding case.
Please use our patient survey inner ear to describe your current problems with the organs in your inner ear

Please enclose your latest audiogram and return these two forms to us by post or fax them to the following number:
08531-980119
You can also contact us per internet as follows:
www.dr-wilden.de
E-Mail: info@dr-wilden.de

Please phone us one or two days after sending the forms under phone number: 08531-980198

Mailing address:
Private practice
Dr. Lutz Wilden
Kurallee 16
94072 Bad Füssing

Patient survey inner ear

Problems with the inner ear:
deafness tinnitus vertigo pressure in the ear	Others:

What has been done up to now?
oxygen therapy autogenic training infusions	pressure chamber acupuncture laser therapy

When did this happen for the first time?

(Month / Year)

Please describe your tinnitus!

(sound level, quality, volume, left? right?)

Do you wear a hearing aid? If so, since when?
Yes (since when )	No

Family/hereditary factors?

Have you suffered from acute trauma?
operation accident psychic-physical stress noise	sudden loss of hearing bang trauma Others:

Are you currently taking medication? If so, which?
Yes (which? )	No

Has a nuclear spin tomography of your head already excluded a brain tumor (e.g. acoustic neurinoma)?
Yes	No

How are you insured?
state insurance	private insurence

Please describe your situation in your own words!

Your Data?
Name:		First name:
Address:		Age:
Post code/Place:		Phone Number:
Job:		E-Mail:

Of course we keep your data in confidence!