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The COVID-19 Long Haul Foundation

Treatment, Referral & Educational Support for Illnesses & Vaccine Injury

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COVID-19 Hearing History

Please Fill Out This Quick History of Your Hearing Prior to Contracting COVID-19. This allows a baseline from which to measure new problems that you are experiencing as a result of Long-haul disease.

Date of Birth

Prior to Contracting COVID-19 My Hearing Was:

Excellent
Good
Fair
Poor

Prior to Contracting COVID-19 My Ability To Hear Was:

Good for Both Ears
Right Better Than Left
Left Better Than Right
Don't Know

In The Past Did You Have Any or Exposure to Any of the Following:

Frequent Ear Aches
Frequent Colds
Strep Infections
Tonsillitis
Tonsillectomy
Tinnitus
Ear Tubes
Perforated Ear Drums
Head Injury
Ear Surgery
Ear Injury
Meniere's Disease
Autoimmune Disease
Exposure to Loud Noises
Acoustic Neuroma
Exposure to Severe Vibration
Gun or Rifle Fire
Altitude/Depth Pressure

Have You Taken Any of the Following:

Streptomycin-Neomycin-Kanamycin
Large Aspirin Doses
Lasix
Chemotherapeutics

Have You Ever Visited a Physician or Audiologist for Hearing Problems?

Yes
No

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