615-988-9787 or 615-740-5233 info@entsinusandallergy.com

PATIENT FORMS

Please download and fill out the following forms if:

  • you feel it may be helpful for your appointment with Dr. Roth
  • you have been asked to bring it to your appointment

 

  1. HEAR 14 (Hearing Evaluation and Auditory Rehabilitation)
    For those having problems with hearing loss
  2. VOICE FUNCTION (Voice Function Outcome Measure)
    For those having trouble speaking or communicating
  3. DIZZINESS (VESTIBULAR & OCULOMOTOR DIZZINESS PATIENT-ORIENTED SEVERITY INDEX)
    For those having trouble with dizziness or seeing objects moving
  4. SNOT-20 (SINO-NASAL OUTCOME TEST)
    For those having trouble with sneezing, runny nose, coughing and other sinus related problems
  5. EPWORTH SLEEPINESS SCALE
    For those having trouble dozing off or falling asleep