Download Adult hearing aid NON MERGE - Croydon Health Services NHS

ADULT HEARING AID ASSESSMENT REFERRAL FORM
PLEASE FAX THIS FORM TO THE CROYDON UNIVERSITY HOSPITAL HEARING CENTRE: 020 8401 3061
Referring Clinician
Referrer Name
Referring Practice
Practice Address
Date of Referral
Tel Number
Fax Number
Postcode
Patient Details
Name
Address
NHS Number
DOB:
Tel No (Home)
Tel No (Work)
Mobile Number
Gender
Postcode
Ethnic Origin
Service Specific Referral Information

If one or more of the boxes below is “NOT ACCEPTED”, please consider a referral to ENT. The referral will otherwise be rejected.
1 – Age
PATIENT INFORMATION - Please answer all the categories
This patient is > 60 years of age
2 – Ear Exam
Both ears are clear of wax
Eardrums intact and healthy
3 – Symptoms
Hearing loss is the same in both ears
Onset of the hearing loss was gradual
Otalgia and or discharge in the last 90 days
Date:
Released 28 February 2011
840996493
NOT ACCEPTED
Yes
NOT ACCEPTED
Yes
NOT ACCEPTED
Yes
NOT ACCEPTED
NOT ACCEPTED
No
NOT ACCEPTED
No
NOT ACCEPTED
No
Yes
No
Yes
No
Patient eyesight good
If NO Specify:
Yes
No
Patient dexterity good
If NO Specify:
Yes
No
This patient is an existing NHS hearing aid user
Yes
No
Tinnitus that is unilateral / pulsating / distressing
Service Information
Provider details
Yes
No
Dizziness in the last 90 days
5.
NOT ACCEPTED
NOT ACCEPTED
The hearing loss is fluctuating
4 – Additional
Information
Yes
Previous surgery to the ears
If YES Specify:
Patient needs a language interpreter
If YES Specify:
Please click here
NHS Number: