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] E N N 8 d \ < J L = = = bJ dJ dJ dJ dJ dJ dJ $ M 1P J = < = @ = = J J HB HB HB = ( bJ HB = bJ HB HB : FG , b J G V p> j rG
NJ J 0 J |G R P > T P G P G = = HB = = = = = J J .@ = = = J = = = = P = = = = = = = = = N n : Adult Audiology Referral Form
PLEASE TICK WHERE THE PATIENT WOULD LIKE TO BE SEEN:
St Anns Hospital Hospital
PLEASE NOTE THAT ALL SECTIONS WILL NEED TO BE FULLY COMPLETED OR THE REFERRAL WILL BE RETURNED
PATIENT DETAILS (BLOCK CAPITALS)First NameNHS NumberSurnameTransport required?Yes / No
D.O.BEscort / Wheelchair / Other (please specify)Gender Male / FemaleInterpreter RequiredYes / No Address
Language SpokenPostcodeTelephone NumberREFERRER DETAILS (BLOCK CAPITALS)Name Designation Address
Email Telephone numberPostcode Date of Referral GP DETAILS (BLOCK CAPITALS)Name Telephone Address
Postcode
Patient NameNHS Number
REASON FOR REFERRAL - PLEASE INCLUDE ANY MEDICATION AND MEDICAL CONDITIONS IN THIS SECTION
History PLEASE NOTE THAT IF ANY SECTIONS ARE MARKED AS YES FOR THE ADULT AUDIOLOGY SERVICE AT THE WHITTINGTON PLEASE REFER DIRECTLY TO ENTPersistent pain affecting either ear (defined as earache lasting more than 7 days in the past 90 days before appointment) Yes / No History of discharge other than wax from either ear within the last 90 days Yes / No Sudden loss or sudden deterioration of hearing (sudden=within 1 week, in which case send to A&E or Urgent Care ENT clinic) Yes / No Rapid loss or rapid deterioration of hearing (rapid=90 days or less) Yes / No Fluctuating hearing loss, other than associated with colds Yes / No Unilateral or asymmetrical, or pulsatile or distressing tinnitus lasting more than 5 minutes at a time Yes / No Troublesome, tinnitus which may lead to sleep disturbance or be associated with symptoms of anxiety or depression Yes / No Abnormal auditory perceptions (dysacuses) Yes / No Vertigo including dizziness, swaying or floating sensations Yes / No Normal peripheral hearing but with abnormal difficulty hearing in noisy backgrounds; possibly having problems with sound localization, or difficulty following complex auditory directions. Yes / No Ear examination - PLEASE NOTE THAT IF ANY SECTIONS ARE MARKED AS YES FOR THE ADULT AUDIOLOGY SERVICE AT THE WHITTINGTON PLEASE REFER DIRECTLY TO ENTComplete or partial obstruction of the external auditory canal preventing proper examination of the eardrum and/or proper taking of an aural impression. Yes / No Abnormal appearance of the outer ear and/or the eardrum (e.g., inflammation of the external auditory canal, perforated eardrum; active discharge). Yes / No
Has this referral been discussed with and agreed by the Patient Yes ( No (
PLEASE NOTE THAT WE OPERATE A PARTIAL BOOKING SERVICE FOR SOME PATIENTS.
IF PATIENTS FAIL TO RESPOND TO A PARIAL BOOKING LETTER, THEY WILL BE DISCHARGED BACK TO THE REFERRER.
Has partial booking been discussed with and agreed by the Patient? Yes ( No (Otoscopy completed and patients ears free of partial/completely occluding wax Yes ( No (
IF NO, THEN PLEASE ARRANGE FOR WAX REMOVAL BEFORE REFERRING THE PATIENT TO AUDIOLOGY
PLEASE NOT THAT PATIENTS PRESENTING WITH OCCLUDING WAX PREVENTING ASSESSMENT IN THE CLINIC MAY BE DISCHARGED BACK TO THE REFERRER
END OF REFERRAL FORM PLEASE SEND ALL PAGES FOR PROCESSING
For Office use only: PLEASE CIRCLE Triaging Info: Direct Referral / Adult Doctor Clinic / NOC
Time Frame: Routine / Urgent / .
Page PAGE 2 of NUMPAGES 2
Page PAGE 1 of NUMPAGES 2
Adult Service Audiology Hospital, Magdala Avenue, N19 5NF
Tel: 0207 288 5220
Email: HYPERLINK "mailto:whh-tr.Audiology-WhittHealth@nhs.net" whh-tr.Audiology-WhittHealth@nhs.net
CAMDEN & ISLINGTON
Audio Vestibular Medicine Service,
St Ann's Hospital, St Ann's Road, N15 3TH
Tel: 0208 702 4660/5629/3101/5385 Email: HYPERLINK "mailto:whh-tr.StAnns-Audiology@nhs.net" whh-tr.StAnns-Audiology@nhs.net
HARINGEY ADULTS
Health Audiology
PLEASE TURN OVER TO COMPLETE FORM
PLEASE TURN OVER TO COMPLETE FORM
PLEASE TURN OVER TO COMPLETE FORM
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