HEARING ASSESSMENT MEDICAL HISTORY & CONSENT FORM
VALE HEARING HEALTH CARE
Full Name
*
First Name
Last Name
Address
*
House Name / Number
Street
Town / City
County
Post Code
Phone Number
*
Email Address
*
Confirmation Email
Email 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?
*
Please Select
Google
Facebook
Local Advert / Business
Doctors Surgery
Hospital Referral
Other
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 From Any Ear?
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Yes
No
As An Adult, Have You Ever Had More Than One Infection In The Same Ear During One Year?
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Yes
No
Any Pus Or Blood in Your Ears?
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Yes
No
Any Persistent Pain In Or Around Either Ear?
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Yes
No
Any Sudden Change In Hearing in One Or Both Ears?
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Yes
No
A Head Cold Or Sinus Problem That Made Your Hearing Worse?
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Yes
No
Any Rotational Vertigo ( Sensations Of The Room Spinning? )
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Yes
No
Have You Ever Been Told By A Physician That You Have Meniere's Disease?
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Yes
No
Fallen Because Of Poor Balance?
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Yes
No
Pressure Or Fullness In Any Ear?
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Yes
No
Do You Have A History Of Noise Exposure?
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Yes
No
Do You Have Any Tinnitus, Such As Ringing, Roaring, Buzzing or Hissing In Your Ears?
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Yes
No
If Yes Please Answer
Left
Right
Both
Unsure
Have You Ever Had Any Of The Following Symptoms Lasting Longer Than 10 Minutes?
Sudden Drop In Hearing In One Or Both Ears?
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Yes
No
Do You Hear Better In One Ear Or The Other?
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Left
Right
Both Equal
If Suffering From Impacted Wax, Have You Tried To Remove The Wax Yourself?
Yes
No
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?
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Yes
No
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?
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Yes
No
If Yes Please Give Details Below
Overall, How Would You Rate Your Health?
*
Please Select
Very Good
Good
Poor
Very Poor
Do You Wear Glasses For Reading?
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Yes
No
Do You Take Any Blood Thinning ( Anticoagulant ) Medication?
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Yes
No
Have You Been Diagnosed With Any Memory Problems Such As Dementia?
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Yes
No
Do You Have Any Physical Disabilities?
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Yes
No
If Yes Please Give Details Below
Do You Live Alone?
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Yes
No
Do You Have Any Difficulty Hearing The Following?
The Telephone Or Door Bell Ringing?
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Yes
No
Is It Hard To Hear The Conversation On The Telephone?
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Yes
No
Listening To The Television?
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Yes
No
Conversation With One Person Face To Face?
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Yes
No
Conversation In A Group Of More Than 2 People?
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Yes
No
Conversation In A Social Environment When There Is Background Noise?
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Yes
No
Conversation When Travelling In The Car Or Other Forms Of Transport?
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Yes
No
TERMS AND CONDITIONS
PLEASE READ THE TERMS AND CONDITIONS BEFORE SUBMITTING YOUR APPLICATION
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?
*
Yes
No
If Yes Enter Your Full Contact Details And Address Below. Please Mention Your Legal Entitlement To Act On The Behalf Of The Potential Patient.
Please verify that you are human
*
Submit
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