Hearbase Forms – Hearbase

Patient's First and Last Name*

Patient's Date of Birth*

Select your form type*

Audiologist*

GDPR Form- What we do with your information

If you would like us to remain in touch please read and consent to the following. 1) Your information will be used in a way that is relevant, clear and unambiguous. 2) We will only use your information to contact you and discuss your specific hearing loss. 3) Your information will NOT be sold or given to 3rd party organisations without your express approval. 4) If you wish to withdraw your consent at any point, we will erase all possible data (within legal permission).

To be reminded about your regular hearing checks?*

Yes
No

To be reminded when you are due to upgrade your hearing aid?*

Yes
No

To share our monthly newsletter?*

The newsletter contains information about your audiologist and free advice to support your hearing health.

Yes
No

Patient's Email for monthly newsletter*

Are you a tablet or desktop user?*

The answer to this field will determine if you are able to collate consent via a signature or checkbox. Tablet users should always gather consent via signature.

Tablet user
Desktop user

Consent*

I agree to the privacy policy.

By agreeing to consent you (the patient) have read the 'What we do with your information' section above and consent to your selected contact methods.

Date Signed*

Consent Signature*

By agreeing to consent you (the patient) have read the 'What we do with your information' section above and consent to your selected contact methods.

Wax Removal Form

Location the patient is being seen?*

Have you had ear wax removed from your ear previously?*

Yes
No

If yes, which method was used?*

More than one option can be chosen.

Water Irrigation
Micro-suction
Manual Instruments
Patient is unsure

How long ago was your wax removal?*

Less than 6 months ago
Over 6 months ago
Over 12 months ago

How often do you have wax removal?*

Every 6 months
Every 12 months

Are you currently under an ENT consultant or receiving any treatment regarding your ears?*

Yes
No

If yes, please provide further details?*

Were you aware of any problems with your hearing or balance before your wax build up?*

Yes
No

If yes, please provide further details?*

Have you ever had a perforated eardrum?*

Yes
No

If yes, which eardrum was perforated?*

Left
Right
Both

When did this occur?*

The date doesn't have to be exact, if you are not sure, please provide your best approximation?

When did this occur?*

The date doesn't have to be exact, if you are not sure, please provide your best approximation.

Are you aware if your eardrum is still perforated?*

Yes
No

Have you suffered from any pain in your ears within the last 30 days?*

Yes
No

Are you using any anticoagulants?*

eg. Warfarin

Yes
No

Your Audiologist

The clinician will examine your ears and discuss the most appropriate method of wax removal for your particular needs.

Your Treatment

The clinician has undertaken training and achieved competency in wax removal and will use best practice procedures to remove the wax from your ear. You should be aware that there is a small risk involved of damage to or infection to skin of the ear canal or the eardrum during the procedure.

Please Note

The CE marked suction unit used for micro-suction is designed to remove fluids from the airway or respiratory support system and infectious materials from wounds. This machine has been adapted for the use of aural micro-suction. By agreeing to these terms and conditions, you accept that you have read and understood the possible complications that may occur.

GDPR Wax Removal- What we do with your information

If you would like us to remain in touch please read and consent to the following. 1) Your information will be used in a way that is relevant, clear and unambiguous. 2) We will only use your information to contact you and discuss your specific hearing loss. 3) Your information will NOT be sold or given to 3rd party organisations without your express approval. 4) If you wish to withdraw your consent at any point, we will erase all possible data (within legal permission).

To be reminded about your regular wax checks/treatments?*

Yes
No

To share our monthly newsletter?*

The newsletter contains information about your audiologist and free advice to support your hearing health.

Yes
No

Patient's Email for monthly newsletter*

Are you a tablet or desktop user?*

The answer to this field will determine if you are able to collate consent via a signature or checkbox. Tablet users should always gather consent via signature.

Tablet user
Desktop user

Wax Removal and GDPR Consent*

I agree to the privacy policy.

By agreeing to consent you (the patient) have read the 'Your Treatment' and 'Your Audiologist' section above and consent to the treatment with the understanding there is a small risk involved.

You (the patient) also confirm you have read, selected and consent to your selected contact methods.

Date Signed*

Consent Signature*

By agreeing to consent you (the patient) have read the 'Your Treatment' and 'Your Audiologist' section above and consent to the treatment with the understanding there is a small risk involved. You (the patient) also confirm you have read, selected and consent to your selected contact methods.

Medical Lifestyle Questionnaire

Do you currently have NHS or Private hearing aids?*

Yes
No

If yes, please confirm what hearing aids you currently have?*

More than one option can be selected

NHS - Right ear
NHS - Left ear
NHS - Binaural
Private - Right ear
Private - Left ear
Private - Binaural

Have you noticed any discharge other than wax form your ears in the past 90 days?*

Yes
No

Which is your better ear?*

Left
Right
Not Sure/No Difference

Have you noticed if your hearing has been fluctuating during the past 90 days?*

Yes
No

Fluctuating Hearing- if required enter comments or notes on the above question.

Do you recall having problems with your ears as a child?*

Yes
No

Problems as a child- if required enter comments or notes on the above question.

Have you consulted anyone previously in connection with your hearing difficulty?*

Yes
No

Consulted Anyone- if required enter comments or notes on the above question.

Is there any history of hearing loss in your family?*

Yes
No

History of Hearing Loss- if required enter comments or notes on the above question.

Have you had exposure to excessive noise in the past 5 years?*

Yes
No

Do you suffer from Vertigo or any balance problems?*

Yes
No

Have you visited a Doctor about earache in the past 90 days?*

referable if lasted longer than 1 week.

Yes
No

Has your hearing loss been sudden or rapid in nature?*

referable if lasted longer than 1 week.

Yes
No

Do you suffer from tinnitus? (ringing or buzzing noises in your ears or head)*

referable if within 90 days.

Yes
No

Do you suffer from tinnitus - enter comments or notes on the above question.*

Are you aware of any problem with your hearing?*

referable if within 90 days.

Yes
No

How long ago did you first become aware of problems with your hearing?*

If you are not sure, please select your best approximation

date pick- How long ago did you first become aware of problems with your hearing?*

If you are not sure, please select your best approximation.

Do you find yourself having to ask people to repeat themselves when you are in conversation?*

Yes
No

Do you have problems hearing children's voices or the voices of other people who are softly spoken?*

Yes
No

Do you go to church, theatre or other public places on a regular basis?*

Yes
No

Have you ever had an operation in your ears?*

Yes
No

Operation in your ears - enter comments or notes on the above question.*

Have you ever had a PVP shunt fitted?*

Yes
No

PVP shunt fitted - enter comments or notes on the above question.*

Make any further comments below. Pay particular attention to items highlighted as referable as it may constitute a referable condition under the HAC code.

MLQ date captured

Hearing Instrument Loan/Trial Form

Is the hearing instrument being provided as a loan or trial?*

Loan
Trial

Which ear/s will the patient be receiving a trial for?*

Left Ear
Right Ear
Both Ears

Hearing Instrument Details

LEFT EAR - make*

LEFT EAR - model*

LEFT EAR - serial number*

LEFT EAR - item value*

RIGHT EAR - make*

RIGHT EAR - model*

RIGHT EAR - serial number*

RIGHT EAR - item value*

Additional notes

Date Signed*

Signature*

By agreeing to consent you (the patient) acknowledge receipt of the hearing instrument for trial or on loan as agreed previously. The instrument/s details as well as the replacement value of this equipment is listed on this document under ‘Hearing Instrument Details’. - I (the patient) understand that the care of the equipment listed on this document under ‘Hearing Instrument Details’ is my responsibility during the loan/trial period (normally 14 or 30 days, though this may be extended at the discretion of Hearbase ltd) and that I will be responsible for any loss or damage to the equipment whilst it is in my care.

Patient Feedback

*Other*

please add your name and the audiologist, if applicable

Patient Email*

Simply enter the patient's email address. The patient will then receive an email with a link to a page on the Hearbase website in which they can leave their comments. Patient feedback is invaluable, good or bad.

Your Treatment

The clinician will use best practice procedures to remove the foreign object from your ear. You should be aware that there is a small risk involved of damage to or infection to skin of the ear canal or the eardrum during the procedure.

Foreign Object Removal

A foreign object refers to any object that is placed in the ear, which is not meant to be there. It could cause harm without medical attention i.e. being removed.

Date Signed*

Consent Signature*

By agreeing to consent you (the patient) have read the above 'Foreign Object Removal' and 'Your Treatment' section above and consent to the treatment with the understanding there is a small risk involved.

Individual Management Plan

Hearing Test Results*

Does the hearing loss require the use of a hearing aid(s)?*

Yes
No

If yes, are the hearing aid(s) require for the Right, Left or Binaural?*

Right
Left
Binaural

What type of ear piece is recommended?*

Open-fit
Standard earmould

Open Fit - Left - Please select the fit type*

Open Fit - Right - Please select the fit type*

Standard Fit - Please note the Standard Fit below*

Presence of referable condition?*

Yes
No

Yes- Please select the referable condition*

Is the use of additional equipment recommended?*

Yes
No

Yes - Please specify the additional equipment required.*

Are lip-reading classes recommended?*

Yes
No

Plan of action

Client Oriented Scale of Improvement (COSI):

Phase 1: Identification of specific listening situations.*

At least 1/5 answers are required. Listening Situation 1.

Listening Situation 2.

Listening Situation 3.

Listening Situation 4.

Listening Situation 5.

Phase 2: Assessment of improvement and final listening ability.*

Fitting appointment:*

Follow-up:*

Additional notes:

if required

Completed by:*

Date:*

For the patient's copy, please select if they have an active email address or if they require a postal copy*

Email is the preferred option

Enter Patient Email
Patient Requires a Postal Copy

Enter the patients email address*

Double check the patient's email address

CHWEE Patient Aftercare Questionnaire

Patient's NHS Number*

Have you been wearing your hearing aids since receiving them?*

Yes
No

How satisfied were you with the overall service you received from Hearbase?*

Satisfied
Neutral
Not satisfied

How satisfied were you with the quality of information and advice received from Hearbase?*

Satisfied
Neutral
Not satisfied

Do you feel it is easier to communicate with people since receiving your new aids?*

Yes
Sometimes
No

Have your hearing aids improved your quality of life?*

Yes
Sometimes
No

Patient Fitting Checklist

Checklist*

Make sure not to miss any check fields as anything missing will be recorded on submission.

Date*

Patient's Signature*

Patient's Email

The patient will receive a copy of the checklist, FAQ and troubleshooting guide. This field must be complete if the patient has an active email.

Company Registration

Hearbase ltd registered in England. Company registration number 4695866. VAT registration number 683870983. Hearbase ltd provides services on behalf of the NHS and is committed to protecting your personal data in compliance with the DPA 1998. No personal data will be passed on to a third party, other than that which we are contractually obliged to disclose to the NHS

Comments

This field is for validation purposes and should be left unchanged.