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Ear Care Nursing Record Name: Address: Date of Birth: Occupation: Medication: Related to Noise/Dust? Family History of Deafness? Yes / No General Health Problems: Diabetic: Allergies: Verbal Consent obtained: Note: Ototoxic drugs eg. Streptomycin. Assessing Nurse: Date: Yes / No Yes/No Past ENT History Grommets In Situ Mastoid Cleft Palate Recent Ear Infection Surgery on tympanic membrane or other ear surgery Tympanic perforation Ear Infection Ear Pain Ear Discharge History of Impaction Tinnitus Vertigo Itching Hearing Aid Previous Ear Irrigation Hearing Loss Otoscopic Examination Tympanic membrane visible Dryness Scaling Erythema Discharge Oedema Pain Wax Amount & colour Right Ear Left Ear Details Use of Ceruminolytic Agents How much? How often? What kind? Physical Assessment of Pinna Swellings Lesions Mastoid tenderness Ear Care Nursing Record Version 1 18Jan13 Page 1 of 2 DATE APPEARANCE OF EAR DRUM SIGNATURE TREATMENT GIVEN (INCLUDING ADVICE) NOTING ANY ABNORMALITIES Right Ear Left Ear Right Ear Left Ear Right Ear Left Ear Ear Care Guidelines Page 2 of 2