The Ear Foundation Santa Barbara


PET TRIAL DAILY RECORD
TREATMENT PERIOD

NAME _________________________________________________

BOTTLE # _______________ Affected Ear: _____ Right _____ Left

Take the medication as needed. If you can't take or don't need the drops, mark the "not needed today" column.

Take 2-4 drops at a time, but no more than 8 drops per day per nostril.

Rate your symptoms using the following scale:

0 = absent
1 = mildly bothersome
2 = moderately bothersome
3 = severely bothersome
NA = not applicable (you have never had that symptom)

  * Autophonia = your voice or breathing sounds unnaturally loud to you.
** Crackling = you hear crackling in your ear(s) when you say "m" or "n" or breathe.

Date
Not
needed
today
Ear fullness
Autophonia*
Crackling**
Before
drops
After
drops
Before
drops
After
drops
Before
drops
After
drops
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               


If you have questions or if you need support, PLEASE do not hesitate to contact your physician.

Please return this form Dr. DiBartolomeo when it is completed.