Medical Case History Card
Clinician's Name
First Name
Last Name
Optical Practice
Patient's Name
First Name
Last Name
Patient Email Address
Occupation
Sycle ID Number
Preferred communication channel
Letter
Phone
Email
SMS
WhatsApp
Support in attendance
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Reasons for attending the clinic today?
Please Select
Hearing Health Check
Full Hearing Test
Fitting
Rehabilitation
Aftercare
Wax Removal
Service call
Cognivue Assessment
Tympanometry
Appointment Referral Type
Please Select
Brand new to practice
Optical patient new to hearing
Existing patient
General Hearing Health
If you are experiencing difficulties, which ear?
Left Ear
Right Ear
Binaural
How would you score your hearing from 1 to 10 (1 = Poor 10 = Perfect)
How many years has this been an issue?
Progression of hearing loss?
*Sudden (with 72 hours in the last 30 days)
*Rapid (over 72 hours ago but within 4-90 days)
Gradual
Fluctuating
Other
Have you had a hearing test before?
Yes
No
If yes, where was this conducted?
NHS Hospital
AQP Provider
Specsavers
Boots
Amplifon
Amplify
Hidden Hearing
Scrivens
Independant
Rather not say
Was a hearing aid solution provided?
Yes Private
Yes NHS/AQP
No
Not applicable
If "yes" where was the last system provided
Please Select
NHS Hospital
AQP
Specsavers
Boots
Amplifon
Amplify
Hidden Hearing
Scrivens
Independant
Rather not say
How many years ago were they prescribed?
Please Select
Not applicable
1 year
2 years
3 years
4 years
5 years +
When did you last have your eyesight tested?
Invite for a test at the practice
Is there any family history of cognitive decline or brain disease?
Audiological/Otological History
Medical Questions
Ear discharge/drainage in the last 90 days
*Yes
No
History of recurrent ear infections
*Yes
No
Ear pain/discomfort in the last 90 days
*Yes
No
Facial numbness/weakness/paralysis
*Yes
No
Any previous ear surgery
Yes
No
Dizziness/balance problems/falls
*Yes
No
Other
If yes to any of the above, please note any factors/symptoms
Is there tinnitus present
Yes
No
If "yes" please choose from the following
*Unilateral left
*Unilateral Right
*Bilateral & Distressing
Occasional
Continuous
Intermittent
*Pulsatile
Non-pulsatile
History of noise exposure
No
Yes
Industrial Noise
Armed Services
Recreational
Not within the last 24 hours
Are you sensitive to loud sounds
Yes
No
Have you been seen by ENT for any issues/treatment
Yes
No
If yes to any of the above, please add notes:
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Next
General Medical History
How would you rate your general health (1 = Poor 10 = Perfect)
Rate from 1-10
Have you suffered from a recent head, neck injury or fall
*Yes (change to hearing or tinnitus detected)
Yes (no change to hearing ability)
No
Have you had a pace maker implanted
Yes
No
Have you had a PVP Shunt implanted
Yes
No
Drugs/Medication
Dexterity problems (Arthritis)
Migraine
Diabetes
High Blood Pressure
Heart related problems
Stroke
None of the above
Have you been diagnosed with any of the following related to hearing loss
Dementia
Parkinsons
Multiple Sclerosis
Bell's palsy
Cancer/chemotherapy
None of the above
Are you taking medication at the moment
Yes
No
Medication noted below
Drugs/Medication currently taken
Ototoxic
Anti-inflammatory
Antibiotics
Diuretics
Steroids
Chemotherapy
Blood pressure
Blood thinner
Diabetic
Referral to GP/Physician
Yes
No
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Hearing challenges/Areas of difficulties
Where/what do you struggle to hear clearly
TV
Telephone
In groups
Music
Radio/podcasts
In a quiet environment
In a noisy environment
In a car/bus
Cinema/Theatre
Office
Garden
Other
Which types of sounds are more difficult to hear
Husband
Wife
Grandchildren
Male voices
Female voices
Bird song
Telephone ring
Notes
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Next
Diagnostic results
Otoscopy/Video Otoscopy
Consent obtained from patient before proceeding
Yes
No
Otoscopy (Pinna Appearance)
NORMAL
ABNORMAL
INFLAMED/RED
PINNA ABNORMALITY
LESIONS/SCAB/GROWTH
Left Ear
Right Ear
Otoscopy (Ear Canal Appearance)
NORMAL
ABNORMAL
INFLAMMATION
WAX REMOVAL NEEDED
WAX REMOVAL CONDUCTED
DISCHARGE
BONY/SKIN GROWTH
BLOOD
STENOSIS
FUNGAL GROWTH
FORIEGN BODY
Left Ear
Right Ear
Otoscopy (Ear Drum Appearance)
NORMAL
ABNORMAL
SWELLING
PERFORATED
DISCHARGE
TYMPANOSCLEROSIS
PIRULENT MIDDLE EAR EFFUSION
FLUID/BUBBLES BEHIND TM
RETREACTED TM/RETREACTION POCKET
CHOLESTEATOMA
MYRINGOTOMY TUBE
Left Ear
Right Ear
Video Otoscopy performed
Yes
No
Video/Photo of ear canal
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Cancel
of
GP/Physician referral letter
Browse Files
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of
Referral to GP/Physician
Yes
No
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Diagnostic Results
Tympanometry
Patient Consent
Yes
No
Graph Results
A
B
C
As
Ab
Middle Ear Pressure (daPa)
Middle Ear Compliance (cm3)
Ear Canal Volume
File Upload
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Choose a file
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of
Referral to GP/Physician
Yes
No
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Next
Diagnostic Results
Pure Tone Audiometry
250
500
1000
2000
3000
4000
6000
8000HZ
AC Left
AC Right
BC Left
BC Right
500
1000
2000
3000
4000HZ
ULL Left
ULL Right
MCL Left
MCL Right
Masking
Masking Rule 1 applied
Masking Rule 2 applied
Masking Rule 3 applied
Referral to GP/Physician
Yes
No
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Diagnostic Results
QuickSin SNR Scoring
Test 1 SNR Score
Test 2 SNR Score
Average SNR Score
SNR Results
0-3dB Normal
3.5 -7dB Mild SNR Loss
7.5 -15dB Moderate SNR Loss
>15dB Severe SNR Loss
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Screening Results
Cognivue
Average Score
Score
Ranges
Memory
Visuospatial
Executive Function
Reaction Time
Processing Speed
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Assessment Intake
COSI
Assessment - COSI Part 1 (Areas of Difficulty)
Description
CATEGORY (1-5)
Specific listening
Situation 1
Specific listening
Situation 2
Specific listening
Situation 3
Specific listening
Situation 4
Specific listening
Situation5
Follow-up - COSI Part 2 (Areas of Difficulty)
Worse
No Different
Slightly better
Better
Much better
Final Ability
10% 25%
50%
75%
95%
Specific listening
Situation 1
Specific listening
Situation 2
Specific listening
Situation 3
Specific listening
Situation 4
Specific listening
Situation5
Time Stamp At Completion
Hour Minutes
AM
PM
AM/PM Option
Signature from Patient
Signature from Clinician
Refer to HAD
Yes
No
Clinicians Email Address
Your email address
Mentor/Managers Email Address
Send a copy of this report to:
Notes for Mentor/Manager
Please add your questions/observations/point for referral
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Patient Outcome Report
Findings and Recommendations
General Health Condition
Please Select
Excellent
Good
Average
Poor
Otoscopy Results
Left Ear
Right Ear
Clear and healthy
Obstruction found
Inflammation
Ear drum inflammation
Hearing Test Results
Left ear
Right ear
Normal Limits
Mild Loss
Moderate Loss
Severe Loss
Profound Loss
Tympanometry Results
Left Ear
Right Ear
Ear drum in correct position
Fullness of middle ear
Retracted ear drum
Speech in Noise results
Please Select
Normal limits
Mild SNR Loss
Moderate SNR Loss
Severe SNR Loss
Cognitive Screening
Please Select
Green
Yellow
Red
Mixed
Hearing Solution
Option 1
Option 2
Option 3
Hearing Aid Type
Hearing Aid Style
Warranty
Aftercare
Cost
Recommendation Choice
Proceed with hearing solution
Considering Options
Medical Referral
No loss
Further treatment appointment needed
Return for hearing test in 24 months
Further Treatment Appointment
Completed
Appointment Needed
Cost
Amount
Date of Appointment
Wax Removal
Yes
No
Tympanometry
Yes
No
Full Diagnostic Hearing Test
Yes
No
Speech In Noise Test
Yes
No
Cognitive Screening
Yes
No
Patient Referral Report
Yes
No
Fitting
Yes
No
Rehabilitating your hearing will improve:
Submit
Should be Empty: