Audiology self-referral form for Adults

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Audiology self-referral form for adults in Staffordshire and Stoke-on-Trent

Please complete this form to access the self-referral audiology service in Staffordshire and Stoke-on-Trent. Once you have completed the form, please contact your provider of choice via telephone, email or online using the contact details shown here.

Clinic locations are also provided in that link.

If you have difficulties completing this form, please contact your provider of choice directly (contact details can be found via the link above). They will be able to help you to complete this form

1. About your hearing problem.

If you answer YES to any of the questions below, you will not be eligible for the Community Adult Hearing service and should make an appointment with your GP Practice.

Have you experienced:- *

YesNo
Persistent pain affecting either ear lasting more than seven days within the last 90 days.
Any discharge from either ear within the last 90 days other than wax.
Sudden (within seven days) loss or deterioration of hearing not associated with a cold or upper respiratory tract infection. If so, seek medical advice.
Rapid (within 90 days) loss or deterioration of hearing.
Fluctuating hearing loss, other than associated with colds.
History of surgery on the ears other than grommets (unless grommets inserted in the past 12 months).
Vertigo (sensation of you or surroundings spinning) within the last 90 days.
Tinnitus (e.g. internal sounds in the ear) in one or both ears lasting for more than five minutes at a time, or that is in time with your heartbeat/pulse, or that is severe enough to disturb your sleep.
Domicilliary need (housebound/home visit)
 

If you think that you have ear wax please discuss this with your provider of choice. The provider will ensure that if any wax is present at the time of the examination, that requires treatment, they will arrange appropriate onward referral for wax care.

Wax must be dealt with first, as it can sometimes mean a hearing assessment cannot take place, although not always, or the hearing aids cannot be fitted.