RAF - Ear Infection Assessment Form

Ear Infection Assessment Form
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

First Line of Address

Street Address 2

CityCountry

Postcode
Email*
Please check your email address is correct
Phone Number*
Medical History
If you have any severe symptoms, such as significant pain or hearing loss, or need urgent medical attention, please do not use this service and contact your GP or 111.*
Are you or is the patient over the age of 2?*

YesNo
Do you currently have an infection of the outer ear?*

YesNo
Unfortunately we are unable to supply you with medication for an ear infection, please contact your GP.
Have you had a serious reaction or intolerable side effects to neomycin sulfate, dexamethasone, glacial acetic acid or any medications before? If yes, please describe the product and the reaction*

YesNo
Please specify*
Do you have any allergies?*

YesNo
Please specify*
Are you breast-feeding?*

YesNoN/A
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?*

YesNoN/A
Do you have diabetes mellitus?*

YesNo
Do you have any liver or kidney problems?*

YesNo
Please specify*
Are you immunosuppressed due to disease or treatment?*

YesNo
Do you have a perforated ear drum or tympanostomy tube (grommet) fitted in the affected ear?*

YesNo
Do you have an infection anywhere other than in the ear?*

YesNo
Have you had persistent infection for the last 3 months or have you used Otomize spray in the last 3 months?*

YesNo
Do you have any of the following symptoms:*

Significant loss of hearing in the affected earFacial nerve palsy (drooping of the face)FeverSevere headacheVertigoSevere headacheSignificant amount of discharge from ear or swelling of ear canalOpen wounds or damaged skin in affected earExtreme pain or discomfortNone of the above
Please list all symptoms you are experiencing below:*
Do you take any current or repeat medicines, including any medication you buy over the counter?*

YesNo
Please specify*
Please provide details of any recent or past medical history of note (e.g. other conditions you have been treated for):
Unfortunately we are unable to supply you with medication for an ear infection, please contact your GP.
Please note an ear examination will take place during the consultation to confirm a diagnosis. *
Appointment Booking
Collection from:

My Private Chemist

Longcroft House

2-8 Victoria Avenue

EC2M 4NS
Should be Empty:

Ear Infection Assessment Form

Patient Information

Medical History

Appointment Booking