Hearing Assessment

Full Name*

First NameLast Name

Address*

House Name / Number

Street

Town / CityCounty

Post Code

Phone Number*

Email Address*

Confirmation EmailEmail Addresses Must Match

Date Of Birth*

Please Fill This Section in same format as example 31/12/1975

PLEASE ENTER YOUR GP / DOCTORS SURGERY ADDRESS / TOWN*

How Did You Hear About Our Services?*

Any Persistent Discharge From Any Ear?*

YesNo

As An Adult, Have You Ever Had More Than One Infection In The Same Ear During One Year?*

YesNo

Any Pus Or Blood in Your Ears?*

YesNo

Any Persistent Pain In Or Around Either Ear?*

YesNo

Any Sudden Change In Hearing in One Or Both Ears?*

YesNo

A Head Cold Or Sinus Problem That Made Your Hearing Worse?*

YesNo

Any Rotational Vertigo ( Sensations Of The Room Spinning? )*

YesNo

Have You Ever Been Told By A Physician That You Have Meniere's Disease?*

YesNo

Fallen Because Of Poor Balance?*

YesNo

Pressure Or Fullness In Any Ear?*

YesNo

Do You Have A History Of Noise Exposure?*

YesNo

Do You Have Any Tinnitus, Such As Ringing, Roaring, Buzzing or Hissing In Your Ears?*

YesNo

If Yes Please Answer

LeftRightBothUnsure

Sudden Drop In Hearing In One Or Both Ears?*

YesNo

Do You Hear Better In One Ear Or The Other?*

LeftRightBoth Equal

If Suffering From Impacted Wax, Have You Tried To Remove The Wax Yourself?

YesNo

If Yes Please State The Method You Used To Try And Remove The Wax

Have You Had Any Previous Operations On Your Ears, Nose Or Throat?*

YesNo

If Yes Please Give Brief Details Of Operation And How Long Ago

Are You Currently Under An ENT ( Ears, Nose, Throat ) Consultant Or Receiving Any Treatment Regarding Your Ears?*

YesNo

If Yes Please Give Details Below

Overall, How Would You Rate Your Health?*

Do You Wear Glasses For Reading?*

YesNo

Do You Take Any Blood Thinning ( Anticoagulant ) Medication?*

YesNo

Have You Been Diagnosed With Any Memory Problems Such As Dementia?*

YesNo

Do You Have Any Physical Disabilities?*

YesNo

If Yes Please Give Details Below

Do You Live Alone?*

YesNo

The Telephone Or Door Bell Ringing?*

YesNo

Is It Hard To Hear The Conversation On The Telephone?*

YesNo

Listening To The Television?*

YesNo

Conversation With One Person Face To Face?*

YesNo

Conversation In A Group Of More Than 2 People?*

YesNo

Conversation In A Social Environment When There Is Background Noise?*

YesNo

Conversation When Travelling In The Car Or Other Forms Of Transport?*

YesNo

Please Enter Full Name Of Guardian If Patient Is Under The Age Of 18 Years Old

Are You Acting On Behalf Of The Potential Patient?*

YesNo

If Yes Enter Your Full Contact Details And Address Below. Please Mention Your Legal Entitlement To Act On The Behalf Of The Potential Patient.

HEARING ASSESSMENT TERMS
CONSENT FORM FOR GENERAL DISPENSING

Your hearing test will be conducted by a trained HCPC Registered Hearing Aid Dispenser & Audiologist working to best practice and professional protocols.

Very often, appointments may be required for adjustments for your hearing instruments and you should contact the Audiologist if you feel this is required.

The hearing test is a non-invasive procedure. Use of an Otoscope will be required (visual inspection of the outer and inner ear).

Depending on the type of hearing instruments prescribed you may be required to have an impression taken. Soft material especially made for this purpose will be put into your ear canal. Complications from the use of an Otoscope and impression taking are uncommon. Side effects and material risks inherent in the procedure are very uncommon but it has been known that clients may get an infection of the skin of the ear canal or minor bleeding, discomfort, ringing in the ear (tinnitus), or perforation of the eardrum. There is an extremely slight risk that you may feel slight discomfort in your ear canal for a time, also if you have used implements in an attempt to remove your own wax in the past.

The highest standards of infection control are in place to minimise risks. To ensure the risk of complication is minimised, it is essential that accurate past medical history is supplied to our clinicians.

CLIENT CONSENT

I confirm by signing this document that:

• the Audiologist has discussed the risks involved.

• the Audiologist has explained the procedure.

• I have had adequate time to consider the risks detailed in this consent form and the Audiologist has answered fully any concerns I had.

• it is my responsibility to advise the Audiologist if any medical conditions change .

By agreeing to these terms and conditions, I accept that I have read and understand the possible complications that may occur and agree that the Audiologist, or any of its other employees at Vale Hearing Healthcare, cannot be held responsible for them and that I am willing to be bound by them.

HEARING ASSESSMENT MEDICAL HISTORY & CONSENT FORM

General And Medical Information

In The Past 3 Months

Have You Ever Had Any Of The Following Symptoms Lasting Longer Than 10 Minutes?

Do You Have Any Difficulty Hearing The Following?