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Wax Removal Case History
Please leave blank:
Name of Client:
D.O.B:
Postcode:
Practitioner:
Alex Trousdale
Sophie Trousdale
Date / Time:
Consents (Please tick all):
Explanation of the 3 methods of wax removal and consent given to allow the procedure most appropriate
Noise aspect of microsuction and possible threshold shift covered
Slightly raised infection risk with irrigation covered
Advised procedure can be terminated at any time by either party if necessary
Advised to keep ears dry for 4 days following wax removal
1). Have you ever had wax removed from your ears previously (Please tick at least one):
Microsuction
Ear Irrigation
Own attempts
Other
None
2). Contra-indications to Microsuction (Please tick at least one):
Previous microsuction problems
History of severe dizziness
Unpredictable head movements
Undue sensitivity to loud noise
None
Detail – Contra-Indications to Microsuction: Only complete if anything of note:
3). Contra-indications to Ear Irrigation (Please tick at least one):
Problems with ear irrigation previously
Confirmed middle ear infections within last 6 weeks
Recent outer ear infection with pain / tenderness (Acute Otitis Externa)
Cleft Palate (Repaired or not repaired)
Perforated ear drum not healed
Discharging ear within last year
Ear Surgery (apart from grommets that have extruded at least 18 months previously and documented ear drum is intact)
None
Detail – Contra-indications to Irrigation: Only complete if anything of note:
4). Precautions to Ear Irrigation (Please tick at least one):
Previous perf confirmed healed by GP / Specialist
Prominent tinnitus
Impaired immune system (Diabetes, HIV, Hepatitis etc)
Balance problems
Medication – Anticoagulants (excluding aspirin) / high dose steroids / chemo
Radiotherapy of head / neck area, potential thin delicate skin prone to trauma
None
Details – Precautions to Irrigation: Only complete if anything of note:
5). Other Contra-Indications and Precautions (Please tick at least one):
Previous Head Injuries
Allergies
Ear Protection Wearer
Hearing Aid Wearer
Cotton Buds
Oil Applied
No Oil Applied
Previous ENT History
Tell us if uncomfortable or a reason to not proceed!
Details – Other Contra – Indications and Precautions:
Results (Please tick at least one):
Right Ear Cleared
Left Ear Cleared
Both Ears Cleared
Both Ears No Wax
Olive Oil Used
Sodium Bicarb Used
< 1 Week Oil Applied
> 1 Week Oil Applied
> 2 Weeks Oil Applied
Microsuction Used
Irrigation Used
Dry Removal Used
TM’s Visible
Hearing Improved
Tinnitus Improved
Client Happy
Follow Up Required
Case Notes: Only complete if anything of note (including tympanometry results):
Right Ear 500Hz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
Left ear 500Hz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
Right Ear 1kHz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
Left ear 1kHz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
Right Ear 2kHz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
Left Ear 2kHz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
Right Ear 4kHz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
Left Ear 4 kHz:
(Choose if tested)
<=15dB
20dB
25dB
30dB
35dB
40dB
45dB
50dB
>50dB
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