WAX HISTORY FORM

To be completed in full by patient prior to appointment being booked.

Please provide answers to all of the questions below as these will assist our nursing team in providing you with the best care at your appointment.

Which House of Hearing clinic is your appointment booked into?
Personal information
My contact details are
Doctors details
How did you hear about us

Current Ear Symptoms

Please provide as much information about the symptoms you are currently experiencing.

Comments (including how long, how bad)

Blocked ear(s)

Comments (including how long, how bad)

Difficulty hearing

Comments (including how long, how bad)

Ear pain

Comments (including how long, how bad)

Tinnitus (eg. ringing/buzzing)

Comments (including how long, how bad)

Dizziness

Comments (including how long, how bad)

Discharge or bleeding from ear

Comments (including how long, how bad)

Sensitive to noise

Comments (including how long, how bad)

Itchiness/eczema/psoriasis

Comments (including how long, how bad)

Are you a hearing aid user?

Comments (including how long, how bad)

Do you use cotton buds?
Any other symptoms not mentioned above

Ear History

Further Information (including when)

Have you had an ear infection in the last 90 days?

Further Information (including when)

If yes, did you require antibiotics?

Further Information (including when)

Have you or do you have a perforated / burst eardrum?

Further Information (including when)

Have you previously suffered from dizzy spells/vertigo?

Further Information (including when)

Have you ever had an operation performed on your ears ?

Further Information (including when)

Previous Ear Treatment

Did you experience any problems?

Have you been using ear drops?

Did you experience any problems?

If so, how long?
Please stop using ear drops
prior to your appointment
Have you ever had your ears syringed/irrigated (using a jet of water) before?

Did you experience any problems?

Have you ever had microsuction before?

Did you experience any problems?

Medical History

Further Information

Are you Diabetic?

Further Information

Are your ears regularly under water eg. When swimming?

Further Information

Do you suffer from sinus or nasal problems or have a cleft palate?

Further Information

Do you have any allergies? (please provide details)

Further Information

Have you previously had an Ear, Nose and Throat consultation?

Further Information

Have you ever had radiotherapy to your head or neck?

Further Information

Are you currently on any anticoagulant medication / blood thinners? eg. Warfarin, Alteplase, Apixoban, Asprin (please provide details)

Further Information

Do you have any other medical conditions or medication that you think we should be aware of eg. High blood pressure medication

Further Information

Signed
Thank you for taking the time to complete this form.

Our Clinics

All House of Hearing clinics are in town centre locations and accessible to public transport and parking. Home visits also available if mobility is an issue.

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