Any Qualified Provider (aqp) for Adult Hearing Services Proforma for Referral for Assessment




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Any Qualified Provider (AQP) for Adult Hearing Services

Proforma for Referral for Assessment


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First Names:




Address line 1:







Last Name:




Address line 2:







NHS Number:




Town:







Date of Birth:




County:







Phone:




Post Code:

   




Phone 2:












Referrer




Practice Name:










Referrer name:




Phone:










Priority: Urgent Routine







Yes




No






Is the patient under 55 years of age






Does the patient have any of the following symptoms:






Persistent pain affecting either ear (defined as earache lasting more than 7 days in the past 90 days before appointment)








History of discharge other than wax from either ear within the last 90 days








Sudden or rapid loss or deterioration of hearing (sudden=within 1 week, in which case sent to A&E or urgent care ENT clinic, rapid = 90 days or less)








Fluctuating hearing loss, other than associated with colds








Unilateral or asymmetrical, or pulsatile or distressing tinnitus lasting more than 5 minutes at a time. Troublesome tinnitus, which may lead to sleep disturbance or be associated with symptoms of anxiety or depression








Vertigo inducing dizziness, swaying or floating sensations





















On Examination of the Ear









Complete or partial obstruction of the external auditory canal preventing proper examination or abnormal appearance of the outer ear and/or the eardrum (e.g. inflammation of the external auditory canal, perforated eardrum; active discharge)





















NOTES:
If NO is ticked for all of the above statements, the patient is suitable for AQP and referral can be made to one of the providers listed on Choose and Book as a provider of AQP Adult Hearing Services.
If YES is ticked to ANY of the above statements, the patient is unsuitable for AQP and therefore a referral should be made to Audiology/ENT through the normal referral pathway.











DOMICILIARY VISITS:

Does the patient require a domiciliary visit? If so, please confirm that the patient is housebound and is unable to leave their home environment without assistance.









AQP Adult Hearing Referral Proforma v1


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