Hearing Aid Direct Referral Form - PDF Document

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  1. Hearing Aid Direct Referral Form Please send this form to: Dept of Audiology, L36, Lister Hospital, Coreys Mill Lane, Stevenage, Herts, SG1 4AB Patients Details: Surname: ____________________________ Forename: __________________________________ Date of birth: _________________________ Hospital Number: ______________________ NHS Number: ________________________________ Address: __________________________________________________________________________ _____________________________________ Postcode: ___________________________________ Home Tel: ____________________________ Mobile Tel: __________________________________ Referring GP Details: GP Name: ____________________________ Surgery address: ____________________________________________________________________ Surgery Tel: ____________________________ Surgery Fax: ______________________________ Clinical Details: (Please tick boxes) All criteria must be met otherwise please refer to ENT. The patient is over 60 years old Has patient worn hearing aids before? Yes No Both ears are free of wax No Tinnitus No Otalgia No Vertigo No evidence of middle ear infection No perforation Weber test is central (No unilateral hearing loss) Rinne test is positive (Air conduction better than bone conduction) No sudden onset of hearing loss No sudden worsening of an existing hearing loss If a patient fails to meet the Hearing Aid Direct Referral criteria plea Other Clinical Notes 

  2. If a patient fails to meet the Hearing Aid Direct Referral criteria please send an ENT referral G.P. Guidelines for the Direct Referral of hearing aid patients The patient I. II. III. Must be over 55 years old Must be seen by a GP and ears de-waxed Referral can only be for a hearing aid Direct Referral will be booked into an ENT clinic for the following reasons and returned to the DR pathway once ENT have investigated / treated any referring symptoms. I. II. III. IV. V. VI. VII. VIII. IX. X. If the patient fails to meet the Hearing Aid Direct Referral criteria please send an ENT referral Excessive wax Perforated eardrum Discharging ears Pain Vertigo – not associated with age / mobility impairment Sudden Onset Hearing Loss Sudden deterioration of pre existing hearing loss Fluctuating hearing loss other than due to colds Asymmetric hearing loss Any other unusual presenting features

  3. ENT Referable Conditions for Hearing Aid Direct Referrals The list below is the criteria followed by audiologists in deciding if an ENT opinion must be sought i. Whole or partial obstruction of ear canal which prevent impression taking and close examination of the tympanic membrane. Abnormal appearance of tympanic membrane and / or outer ear. Earache ii. iii. iv. Discharge v. Vertigo vi. Tinnitus, which is causing patient distress. vii. Hearing loss that may be associated with noise exposure within the last 5 years. viii. Conductive hearing loss – 25db air/bone gap at 2 or more frequencies in the 500 – 4000Hz range. ix. Unilateral or asymmetrical hearing loss with a 25db difference between the left & right BC results in at 2 or more frequencies in the 500 – 4000Hz range. x. Sudden hearing loss (24hrs). xi. Rapid hearing loss (90 days). xii. Sudden, rapid or recent worsening of an existing hearing loss. Indicated by an AC difference of 20db at 2 or more frequencies in the 500 – 4000Hz range when comparing 2 audiograms taken within 24 months. xiii. Fluctuating hearing loss not associated with head colds. xiv. Premature hearing loss (18 – 40yo). The loss in either ear should not be greater than 30db in either ear at 2 or more frequencies in the 500 – 4000Hz range. xv. Poorer speech discrimination than would typically be associated with a patients level of hearing. xvi. Patients under the age of 18 years old (Private) or under 60 years old (NHS)