Name of Client *

Postcode *

Practitioner *Please ChooseHelen PateDiane SandersonJacqui SandersonChristine GrangePaul Minikin

Date / Time *

Consents (Please tick all) *

• Explanation of the 3 methods of wax removal and consent given to allow the procedure most appropriate
• Noise aspect of microsuction and possible threshold shift covered
• Slightly raised infection risk with irrigation covered
• Advised procedure can be terminated at any time by either party if necessary

1). Have you ever had wax removed from your ears previously (Please tick at least one) *

• Microsuction
• Ear Irrigation
• Own attempts
• Other
• None

2). Contra-indications to Microsuction (Please tick at least one) *

• Previous microsuction problems
• History of severe dizziness
• Unpredictable head movements
• Undue sensitivity to loud noise
• None

Detail - Contra-Indications to Microsuction

3). Contra-indications to Ear Irrigation (Please tick at least one) *

• Problems with ear irrigation previously
• Confirmed middle ear infections within last 6 weeks
• Recent outer ear infection with pain / tenderness (Acute Otitis Externa)
• Cleft Palate (Repaired or not repaired)
• Perforated ear drum not healed
• Discharging ear within last year
• Ear Surgery (apart from grommets that have extruded at least 18 months previously and documented ear drum is intact)
• None

Detail - Contra-indications to Irrigation

4). Precautions to Ear Irrigation (Please tick at least one) *

• Previous perf confirmed healed by GP / Specialist
• Prominent tinnitus
• Impaired immune system (Diabetes, HIV, Hepatitis etc)
• Balance problems
• Medication - Anticoagulants (excluding aspirin) / high dose steroids / chemo
• Radiotherapy of head / neck area, potential thin delicate skin prone to trauma
• None

Details - Precautions to Irrigation

5). Other Contra-Indications and Precautions (Please tick at least one) *

• Previous Head Injuries
• Allergies
• Ear Protection Wearer
• Hearing Aid Wearer
• Cotton Buds?
• Oil Applied
• No Oil Applied
• Previous ENT History?
• Tell us if uncomfortable or a reason to not proceed!

Details - Other Contra - Indications and Precautions

Results (Please tick at least one) *

• Right Ear Cleared
• Left Ear Cleared
• Both Ears Cleared
• Both Ears No Wax
• Olive Oil Used
• Sodium Bicarb Used
• <= 1 Week Oil Applied
• > 1 Week Oil Applied
• > 2 Weeks Oil Applied
• Microsuction Used
• Irrigation Used
• Dry Removal Used
• TM's Visible
• Hearing Improved
• Tinnitus Improved
• Client Happy
• Follow Up Required

Case Notes

Right Ear 500HzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dB

Right Ear 1kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dB

Right Ear 2kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dB

Right Ear 4kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dB

Left ear 500HzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dB

Left ear 1kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50db

Left Ear 2kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dB

Left Ear 4 kHzChoose if tested15dB20dB25dB30dB35dB40dB45dB50dB>50dB

File Upload

Click or drag a file to this area to upload.

Fee Paid (zero if no fee) *

Payment Method *Please chooseCash PaymentCard PaymentNo Fee

Submit