Electronic Ear

Irrigation Assessment
Form

Surname: Forename(s) D.o.B:

Address: NHS/Hospital No: GP:

If the patient has any of the following – do not proceed with irrigation and refer back
to the GP
Previous complications Yes No
following irrigation
Middle ear infection in the last 6 Yes No
weeks
Any form of ear surgery Yes No
History of mucus discharge Yes No
Cleft palate (repaired or not) Yes No
Perforation – current Yes No
Acute Otitis extrema Yes No
*NB:
Be cautious with patients who have Tinnitus and and dizziness and seek further advice before
proceeding with irrigation
Patients who say they have a healed perforation. You need to establish that it has healed and then if
appropriate proceed with caution.

Is the patient experiencing deafness in:

Right Ear Yes No
Left Ear Yes No
Have they been using softening Yes No
ear drops for 5 – 7 days?
Received patient information Yes No
leaflet
Examination of the Ear externally and with auriscope
Right Ear Left Ear
Yes No Foreign Body Yes No
Yes No Perforation Yes No
Yes No Inflammation Yes No
Yes No Wax Yes No
Yes No Discharge Yes No
Yes No Scarring Yes No
Yes No Extreme Hair Yes No
Yes No Dry Skin Yes No
Yes No Excema Yes No
Yes No Narrow Canal Yes No
Yes No Pain Yes No
Print Full Name: Date:
Signature: Band: