Forms

All patients must fill out the the registration and history forms. Please click below to download the 2 forms.

• Patient History Form
• Patient Information Form

Patients coming in for the first time for dizziness, need to fill out the three forms below:

• Dizziness Questionnaire
• Dizziness Handicap Inventory
• Health Survey

Patients consulting regarding ringing in the ears (tinnitus), need to fill out the two forms below:

• Tinnitus Questionnaire
• Health Survey

All new patients for Dr. Djalilian:

• To make your visit smoother to the ear and skull base clinic, please bring all previous hearing and balance tests with you. Also, please bring copies of any ear or brain imaging studies (CT or MRI) with you. Please bring the films or the CD of the images - the written report is not sufficient.

Post-operative Instructions:

• Instructions for Care after Tympanoplasty, Mastoidectomy, Endolymphatic Sac Procedures
• Instructions for Care after Stapedectomy