ENT Virtual Clinic Pre-appointment Questionnaire

Please complete the questionnaire below and bring it with you to your audiology appointment.

Name:
Hospital number (if known):

1. Have you experienced pain in or around your ear lasting for a week or more in the last three months?
   Yes / No
2. Have you experienced any discharge from your ears (other than wax) in the last 90 days?
   Yes / No
3. Has your hearing loss developed rapidly? (rapid = has it come on in the last 90 days or less?)
   Yes / No
4. Do you experience tinnitus?
   Yes / No
5. If yes do you experience it as coming from one ear only?
   Yes / No
6. Does it sound like your pulse?
   Yes / No
7. Have you experienced vertigo (hallucination of movement) which has not fully resolved, or is recurring?
   Yes / No
8. Have you ever undergone surgery on your ear(s)?
   Yes / No
9. Does your hearing loss fluctuate, other than fluctuations associated with colds?
   Yes / No
10. Have you recently experienced an altered sensation or numbness in your face? Or a facial droop?
    Yes / No