Hearing Assessment

HEARING ASSESSMENT MEDICAL HISTORY & CONSENT FORM

VALE HEARING HEALTH CARE
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?*
General And Medical Information

Please Fill All Questions Below Honestly And To The Best Of Your Knowledge
In The Past 3 Months

Have You Had Any Of The Following Symptoms?
Any Persistent Discharge or Blood From Any Ear?*

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

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 Loud Noise Exposure?*

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

YesNo
If Yes Please Answer

LeftRightBothUnsure
Do You Have A VP (Ventriculo-Peritoneal) Shunt Surgically Implanted into Your Brain? This Is A Treatment For Hydrocephalus To Drain Excess Cerebrospinal Fluid.*

YesNo
Have You Ever Had Any Of The Following Symptoms Lasting Longer Than 10 Minutes?
Sudden Drop In Hearing In One Or Both Ears within the last 30 days?*

YesNo
Have You Experienced A Rapid Deterioration in hearing? Rapid means within the last 4-90 days.

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, Where It Was Performed 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 Medication (Anticoagulant)?*

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
Do You Have Any Difficulty Hearing The Following?
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 The 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, BSHAA registered hearing care professional working to best practice and professional protocols.

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

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:

To the best of my knowledge, I have provided accurate details of my medical hearing history, and it is my responsibility to advise the audiology professional if any of my medical conditions change.

I consent to having a hearing assessment.
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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?