Audiology questionnaire – Chatswood ENT

ENT relevant member(s)

Audiology Pre-Appointment Questionnaire

Patient Information and Consent

Patient title

Title

Patient name *

First

Last

Patient date of birth *

I am completing this form on behalf of someone else *

I/we have already completed the Chatswood ENT patient intake form *

Yes
No
Unable to complete online, will do form by hand upon arrival

*Below is an additional pre-appointment questionnaire for our audiologists

Clinical symptoms and relevant medical history

Not at all	Only noticed in a quiet room	Easily masked by environmental noise	Noticeable even with background noise	Prevents me from sleeping or concentrating	Dominates all waking hours
Not at allItem #1 Not at all	Only noticed in a quiet roomItem #1 Only noticed in a quiet room	Easily masked by environmental noiseItem #1 Easily masked by environmental noise	Noticeable even with background noiseItem #1 Noticeable even with background noise	Prevents me from sleeping or concentratingItem #1 Prevents me from sleeping or concentrating	Dominates all waking hoursItem #1 Dominates all waking hours

Which ear(s) are affected by your symptom(s) *

Left
Right
Both
Unsure

When did the symptom(s) first develop? *

Please include any additional information you would like to share with our clinical team in relation to your symptoms

How would you rate your ability to follow a conversation in the following settings?

	No difficulty	Slight difficulty	Moderate difficulty	Extreme difficulty
WIth background noise (restaurant, indoor sporting event)	No difficultyWIth background noise (restaurant, indoor sporting event) No difficulty	Slight difficultyWIth background noise (restaurant, indoor sporting event) Slight difficulty	Moderate difficultyWIth background noise (restaurant, indoor sporting event) Moderate difficulty	Extreme difficultyWIth background noise (restaurant, indoor sporting event) Extreme difficulty
On the telephone	No difficultyOn the telephone No difficulty	Slight difficultyOn the telephone Slight difficulty	Moderate difficultyOn the telephone Moderate difficulty	Extreme difficultyOn the telephone Extreme difficulty
In a meeting or in the classroom	No difficultyIn a meeting or in the classroom No difficulty	Slight difficultyIn a meeting or in the classroom Slight difficulty	Moderate difficultyIn a meeting or in the classroom Moderate difficulty	Extreme difficultyIn a meeting or in the classroom Extreme difficulty
In a quiet room (one-on-one conversation)	No difficultyIn a quiet room (one-on-one conversation) No difficulty	Slight difficultyIn a quiet room (one-on-one conversation) Slight difficulty	Moderate difficultyIn a quiet room (one-on-one conversation) Moderate difficulty	Extreme difficultyIn a quiet room (one-on-one conversation) Extreme difficulty
Watching TV or a movie	No difficultyWatching TV or a movie No difficulty	Slight difficultyWatching TV or a movie Slight difficulty	Moderate difficultyWatching TV or a movie Moderate difficulty	Extreme difficultyWatching TV or a movie Extreme difficulty

To what degree does your hearing or ear concern impact your daily life?

None at all	Mild	Moderate	Severe
None at allItem #1 None at all	MildItem #1 Mild	ModerateItem #1 Moderate	SevereItem #1 Severe

Have you had your hearing tested before? *

Yes
No
Unsure

Is there any known family history of hearing loss or ear-related conditions? *

Yes
No
Unsure

Have you had surgery on or around your ears (including grommets 'ear tubes')? *

Yes
No
Unsure

Surgery details

Are you prone recurrent ear infections or other recurrent medical illnesses?

Yes
No
Unsure

Please provide details

Do you have any of the following medical conditions? *

Please list any other medical conditions, developmental diagnoses, chronic illnesses

Do you currently use/have hearing aids or hearing augmentation devices?

Yes
No

Please specify type and side(s)

Do you have a shunt or any internal pressure-relief valve implanted in your head or behind your ears?

Yes
No

Left Side, Right Side, Both?

Lifestyle

Do you have a history of exposure to loud noise? *

Yes
No
Unsure

Please describe the duration and type of noise exposure – occupation, hobbies (current or previous as relevant to ongoing or historic noise exposure)

Do you use hearing protection when exposed to loud noise?

Yes
No
Sometimes

Subjective and additional information when this form is completed on behalf of patient

	Not applicable	No difficulty	Slightly difficult	Difficult	Very difficult
In a quiet room	Not applicableIn a quiet room Not applicable	No difficultyIn a quiet room No difficulty	Slightly difficultIn a quiet room Slightly difficult	DifficultIn a quiet room Difficult	Very difficultIn a quiet room Very difficult
In a noisy environment (e.g. restaurant, indoor sporting event)	Not applicableIn a noisy environment (e.g. restaurant, indoor sporting event) Not applicable	No difficultyIn a noisy environment (e.g. restaurant, indoor sporting event) No difficulty	Slightly difficultIn a noisy environment (e.g. restaurant, indoor sporting event) Slightly difficult	DifficultIn a noisy environment (e.g. restaurant, indoor sporting event) Difficult	Very difficultIn a noisy environment (e.g. restaurant, indoor sporting event) Very difficult
On the telephone	Not applicableOn the telephone Not applicable	No difficultyOn the telephone No difficulty	Slightly difficultOn the telephone Slightly difficult	DifficultOn the telephone Difficult	Very difficultOn the telephone Very difficult
In a meeting or classroom environment	Not applicableIn a meeting or classroom environment Not applicable	No difficultyIn a meeting or classroom environment No difficulty	Slightly difficultIn a meeting or classroom environment Slightly difficult	DifficultIn a meeting or classroom environment Difficult	Very difficultIn a meeting or classroom environment Very difficult
Having a conversation with a single person in a quiet environment	Not applicableHaving a conversation with a single person in a quiet environment Not applicable	No difficultyHaving a conversation with a single person in a quiet environment No difficulty	Slightly difficultHaving a conversation with a single person in a quiet environment Slightly difficult	DifficultHaving a conversation with a single person in a quiet environment Difficult	Very difficultHaving a conversation with a single person in a quiet environment Very difficult
Following simple instructions	Not applicableFollowing simple instructions Not applicable	No difficultyFollowing simple instructions No difficulty	Slightly difficultFollowing simple instructions Slightly difficult	DifficultFollowing simple instructions Difficult	Very difficultFollowing simple instructions Very difficult

Is this patient currently under the care of a non-GP specialist or an allied health professional (e.g., speech pathologist, occupational therapist, physiotherapist)?

Yes and we have identified entire health care team on our Chatswood ENT patient intake form
Yes (please list all below)
No
Unsure

Did this patient undergo a newborn hearing screening?

Yes
No
Unsure

What were the results of the hearing screening?

Passed
Referred for further testing
Unsure
Other

Details

Consent

Consent to collect patient information

PRIVACY ACT 1988 • PRIVACY ACT AMENDMENTS-PRIVATE SECTOR-ACT 2000

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.

I have read the information above and understand the reasons why my information must be collected.
I am aware that this practice has a privacy policy on handling patient information.
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might
compromise the quality of the health care and treatment given to me.
I am aware of my right to access the information collected about me, except in some circumstances where access might
legitimately be withheld. I understand I will be given an explanation in these circumstances.
I understand that if I request access to information about me, the practice will be entitled to charge me fees to cover:
- time spent by administrative staff to provide access (at the employee’s hourly rate of pay)
- time spent by a medical practitioner to provide access (at the practitioner’s ordinary sessional rate)
- photocopying and other disbursements at cost

• I understand that if my information is to be used for any purpose other than the above, my consent will be sought.

I/we consent to the handling of my information by the practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

Signature *

Clear Signature

Please use your finger as a stylus if you are using a mobile device. If you are on a computer, click into the signature field to use your mouse or trackpad.

Initials of individual completing form *

Audiology Pre-Appointment Questionnaire

Patient Information and Consent

Please pre register using the link below:

Chatswood ENT New Patient Forms

Clinical symptoms and relevant medical history

Lifestyle

Subjective and additional information when this form is completed on behalf of patient

Consent

Consent to collect patient information

I/we consent to the handling of my information by the practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

Chatswood ENT

Dr Bill Johnston

Associate Professor Raewyn Campbell

Qualified Practitioner Audiology

Address

The Gallery
Level 1, 445 Victoria Ave
Chatswood NSW 2067

Find

Contact

02 9188 9292
referral@chatswoodent.com.au
Healthlink: chatsent
fax: 02 9188 1611

Email

Audiology Pre-Appointment Questionnaire

Patient Information and Consent

Please pre register using the link below:

Chatswood ENT New Patient Forms

Clinical symptoms and relevant medical history

Lifestyle

Subjective and additional information when this form is completed on behalf of patient

Consent

Consent to collect patient information

I/we consent to the handling of my information by the practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

Chatswood ENT

Dr Bill Johnston

Associate Professor Raewyn Campbell

Qualified Practitioner Audiology

Address

The Gallery Level 1, 445 Victoria Ave Chatswood NSW 2067

Find

Contact

02 9188 9292 referral@chatswoodent.com.au Healthlink: chatsent fax: 02 9188 1611

Email

The Gallery
Level 1, 445 Victoria Ave
Chatswood NSW 2067

02 9188 9292
referral@chatswoodent.com.au
Healthlink: chatsent
fax: 02 9188 1611