Pre-Appointment Questions - Herts earwax removal

First Name

Last Name

Email

Do you have any of the following conditions? (please tick all that apply):

Perforated eardrum

Any problems that cause balance problems or vertigo

Pain or discharge in your ears within the last 30 days

Cleft palate

Diabetes

Parkinsons

Tinnitus

If you have ticked YES to tinnitus, is it sound sensitive tinnitus?

Yes

No

N/A

Have you ever had earwax removal before?

Yes

No

Please advise of date of last earwax removal (approx) and where you had earwax removal (if you’ve not, put N/A)

Have you experienced previous problems having microsuction or irrigation?

Yes

No

N/A

If you have selected YES to having experienced any previous problems with microsuction or irrigation, please provide details below? (otherwise please put N/A)

Have you ever had ear, nose or throat surgery?

Yes

No

Are you currently under an ENT consultant or receiving treatment regarding your ears?

Yes

No

Additional Info (if applicable) – If there is anything else that you think I should know in advance of your appointment, please advise here