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Dr. med. Lutz Wilden
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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!


Loss of Hearing | Hearing Loss | Menières Disease | Ear Ringing | Tinnitus Treatment | Menières | Laser Therapy Equipment | Tinnitus Specialist
Menière's Disease | Treatment Vertigo | Treatment Tinnitus | Hearing Loss | Tinnitus | Laser Therapy | Inner ear disease | Inner ear | Low Level Laser Therapy | Low Level Laser Therapy


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