Otalgia (Ear pain) Otalgia (Ear Pain) Screening Questionnaire This tool is for preliminary assessment only and does not replace clinical examination. 1. Pain Characteristics Which ear is affected? Select Left Right Both Onset of pain Select Sudden Gradual Duration Select Less than 1 week 1–4 weeks More than 4 weeks Severity Select Mild Moderate Severe Nature of pain Select Throbbing Sharp Dull ache Burning 2. Ear Symptoms Ear discharge Hearing loss Itching Blocked sensation Tinnitus Vertigo 3. Aggravating Factors Pain on pulling ear / tragal pressure Pain on chewing Pain on swallowing 4. Head & Neck Symptoms Tooth pain Throat pain Jaw pain / clicking Neck pain Change in voice 5. Systemic & Risk Factors Fever Diabetes Smoking / Tobacco use Unexplained weight loss Pain worse at night Generate Result Download PDF