Wax Removal Case History Please enable JavaScript in your browser to complete this form.Name of Client *Postcode *Practitioner *Please ChooseHelen PateDiane SandersonJacqui SandersonChristine GrangePaul MinikinDate / Time *Consents (Please tick all) *Explanation of the 3 methods of wax removal and consent given to allow the procedure most appropriateNoise aspect of microsuction and possible threshold shift coveredSlightly raised infection risk with irrigation coveredAdvised procedure can be terminated at any time by either party if necessary1). Have you ever had wax removed from your ears previously (Please tick at least one) *MicrosuctionEar IrrigationOwn attemptsOtherNone2). Contra-indications to Microsuction (Please tick at least one) *Previous microsuction problemsHistory of severe dizzinessUnpredictable head movementsUndue sensitivity to loud noiseNoneDetail – Contra-Indications to Microsuction3). Contra-indications to Ear Irrigation (Please tick at least one) *Problems with ear irrigation previouslyConfirmed middle ear infections within last 6 weeksRecent outer ear infection with pain / tenderness (Acute Otitis Externa)Cleft Palate (Repaired or not repaired)Perforated ear drum not healedDischarging ear within last yearEar Surgery (apart from grommets that have extruded at least 18 months previously and documented ear drum is intact)NoneDetail – Contra-indications to Irrigation4). Precautions to Ear Irrigation (Please tick at least one) *Previous perf confirmed healed by GP / SpecialistProminent tinnitusImpaired immune system (Diabetes, HIV, Hepatitis etc)Balance problemsMedication – Anticoagulants (excluding aspirin) / high dose steroids / chemoRadiotherapy of head / neck area, potential thin delicate skin prone to traumaNoneDetails – Precautions to Irrigation5). Other Contra-Indications and Precautions (Please tick at least one) *Previous Head InjuriesAllergiesEar Protection WearerHearing Aid WearerCotton Buds?Oil AppliedNo Oil AppliedPrevious ENT History?Tell us if uncomfortable or a reason to not proceed!Details – Other Contra – Indications and PrecautionsResults (Please tick at least one) *Right Ear ClearedLeft Ear ClearedBoth Ears ClearedBoth Ears No WaxOlive Oil UsedSodium Bicarb Used<= 1 Week Oil Applied> 1 Week Oil Applied> 2 Weeks Oil AppliedMicrosuction UsedIrrigation UsedDry Removal UsedTM’s VisibleHearing ImprovedTinnitus ImprovedClient HappyFollow Up RequiredCase NotesRight Ear 500HzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dBRight Ear 1kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dBRight Ear 2kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dBRight Ear 4kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dBLeft ear 500HzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dBLeft ear 1kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dbLeft Ear 2kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dBLeft Ear 4 kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dBFee Paid (zero if no fee) *Payment Method *Please chooseCash PaymentCard PaymentNo FeeSubmit
