Assessment Patient Details*First Name First Last Name Last HiddenD.O.BDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920D.O.B.Day12345678910111213141516171819202122232425262728293031*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderFemaleMaleOtherPrefer not to sayEmail PhoneDiagnosis*Procedure*Left Ear Normal Ear wax Foreign body DetailsLeft Ear Otitis externa Other DetailsRight Ear Normal Ear wax Foreign body DetailsRight Ear Otitis externa Other DetailsLeft Ear No Procedure Microsuction Micro-instrumentation Foreign body removal Pope-wick insertion Book follow-up appointment within 2 - 3 daysRight Ear No Procedure Microsuction Micro-instrumentation Foreign body removal Pope-wick insertion Book follow-up appointment within 2 - 3 daysPost Procedure Examination*Left Ear Normal Other DetailsRight Ear Normal Other DetailsPrescription*Prescription Yes No AllergiesDrug---TOPICAL DRUGS/SPRAYSBetnesolCanestenCilodexCiprofloxacinEarCalmGentamicinGentisone HCOlive OilOtomiseSodium BicarbonateSofradex---NASAL DROPS/SPRAYSBetnesolOtrivine---ORAL ANTIBIOTICAmoxicillinCiprofloxacinClarithromycinCo-AmoxiclavFlucloxacillin---PAIN RELIEFCo-CodamolCodeine PhosphateForm---DropLiquidSprayTabletDose Frequency---ODBDTDSQDS4 HourlyPRNDuration---3 Days5 Days1 Week10 Days2 Weeks4 Weeks6 WeeksDrug---TOPICAL DRUGS/SPRAYSBetnesolCanestenCilodexCiprofloxacinEarCalmGentamicinGentisone HCOlive OilOtomiseSodium BicarbonateSofradex---NASAL DROPS/SPRAYSBetnesolOtrivine---ORAL ANTIBIOTICAmoxicillinCiprofloxacinClarithromycinCo-AmoxiclavFlucloxacillin---PAIN RELIEFCo-CodamolCodeine PhosphateForm---DropLiquidSprayTabletDose Frequency---ODBDTDSQDS4 HourlyPRNDuration---3 Days5 Days1 Week10 Days2 Weeks4 Weeks6 WeeksDrug---TOPICAL DRUGS/SPRAYSBetnesolCanestenCilodexCiprofloxacinEarCalmGentamicinGentisone HCOlive OilOtomiseSodium BicarbonateSofradex---NASAL DROPS/SPRAYSBetnesolOtrivine---ORAL ANTIBIOTICAmoxicillinCiprofloxacinClarithromycinCo-AmoxiclavFlucloxacillin---PAIN RELIEFCo-CodamolCodeine PhosphateForm---DropLiquidSprayTabletDose Frequency---ODBDTDSQDS4 HourlyPRNDuration---3 Days5 Days1 Week10 Days2 Weeks4 Weeks6 WeeksPrescription No. Prescription No Prescription UploadAccepted file types: jpg, png, Max. file size: 8 MB.Follow-up*Follow Up Yes No Next stepsA&EAuris Ear CareGPThe Ear & Hearing Specialist ClinicDate DD slash MM slash YYYY Time000102030405060708091011121314151617181920212223 00153045LocationHomeCare HomeHarley StreetHospitalHotelNursing HomeOffice / WorkplaceResidential HomeRetirement HomeOtherDetailsDetailsSign Off*Clinician---Dr Riaz Rampuri (GMC 7494525)Dr Misha Verkerk (GMC 7304120)Ear care advice given? Ear Wax Ear Infection Foreign Body LocationHomeCare HomeHarley StreetHospitalHotelNursing HomeOffice / WorkplaceResidential HomeRetirement HomeOtherHiddenGPConsent HiddenGPName HiddenGPPractice HiddenGPAddress1 HiddenGPAddress2 HiddenGPPostcode HiddenGPLookup
