Audiology & Ear Care Clinical Report

Complete Patient Assessment, Micro Suction Consent & Audiometry Record

Audiology Practice Management Platform

1. Patient Registration & GP Details (Doc 1 & Doc 2)

2. Micro Suction Wax Removal Consent (Doc 1)

Medical Screening Questionnaire

Balance problems or vertigo attacks?

Vertigo attack within the last 30 days?

Ear pain within the last 30 days?

Perforated ear drum?

If Yes, Which Ear?

Duration (Years / Months)

Tried to remove wax yourself?

Under ENT Consultant / Treatment?

Using anticoagulants (e.g., Warfarin)?

Aware of reason not to proceed?

Previous wax removal?

Terms & Conditions Disclaimer: Micro suction is considered safer than syringing. Rare risks include incomplete removal, minor bleeding, discomfort, tinnitus, perforation, or hearing loss. Patient must remain still during procedure. By signing below, you agree to these terms.

Patient Written / Digital Signature

Consent Date

3. ENT History & Red Flag Screening (Doc 2)

ENT Surgery (Last 5 Yrs)

Family History of Hearing Loss

Prior Hearing Aid Experience

Red Flag Symptoms (Last 90 Days)

Tinnitus (90 Days)

Tinnitus Type

Unilateral Pulsatile Distressing

Tinnitus GP Aware?

Rotary Vertigo (90 Days)

Ear Discharge (Non-wax, 90d)

Ear Pain (>7 days in last 90d)

Noise Exposure / Fluctuation

Medical Referral Required?

Red Flag / Referral Details

4. Otoscopy Examination (Doc 2)

Structure	Right Ear	Left Ear
Tympanic Membrane (TM)
Ear Canal

Obstruction Extent / Details (Right & Left)

Otoscopy Referral Required?

Referral Details

5. Clinical Audiogram Canvas

Ear Side:

Transducer:

Masking Status:

Right: Air (O), Air-Masked (Δ), Bone (<), Bone-Masked ([) Left: Air (X), Air-Masked (□), Bone (>), Bone-Masked (])

Live PTA Calculation (500Hz - 4000Hz Air):

Right Ear PTA: N/A

Left Ear PTA: N/A

6. Audiometry Communication & Hearing Aid Recommendations (Doc 2)

Has patient had a hearing test before?

Instructions Given?

Hearing Loss Explained?

Patient Interested in Hearing Aid?

Where would they most prefer improvement in listening?

Recommended Hearing Aid & Ear Mould Details

7. Saved Audiograms History (MSSQL Database)

Test Date	Audiogram ID	Equipment	Reliability	Hearing Severity (Clinical Diagnosis)	Total Points	Action
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