Get Canada Alberta WCB C042 2010
Ent? Name of doctor(s) Ringing in ears Date If yes, did you receive treatment? Name of doctor(s) Yes No Address Pain and/or discharge from ears Ear Infection Yes If yes, did you receive treatment? Yes No Date No Address Date No If yes, how many years have you had tinnitus/ringing __________ Left Right Both Is noise Constant Intermittent Please outline how this noise affects your usual activities of daily living, i. e. what activities do you have difficulty performing due.
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