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Patient Questionnaire

For: Mia Parker

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Symptoms
Please indicate which symptoms you are experiencing

Pain in or around the ear

Fluid coming from the ear

Difficulty hearing or muffled sounds

Feeling unsteady or lightheaded

Elevated body temperature

Pain in the head or face

Stuffy or runny nose

Pain or irritation in the throat

Persistent or occasional coughing

Feeling unusually tired or exhausted

Itching in or around the ears

Skin rash or irritation