SIOC - Audiology assessment
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East London
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Cape Town
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Oudtshoorn
Paarl
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Stellenbosch
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Vredenburg
Worcester
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Patient Number
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Gender
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Age
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Case History
Hearing Difficulties?
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No
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History of ear infections / discharge
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No
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Family history of HL
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Ear pain
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Tinnitus
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Dizziness
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Medications
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Normal speech / Language development
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Other diagnosis
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Is the child seeing a therapist?
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Previous Audiology / ENT visits
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Capture notes for case history?
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Case History Notes
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Otoscopy
Discharge
(*)
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Wax impaction
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Inflamed eardrum
(*)
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Perforated
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Capture notes for oscopy?
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Otoscopy Notes
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Tympanometry
Right ear
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Type A
Type B
Type C
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Left ear
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Type A
Type B
Type C
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Capture notes for OAE results?
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OAE-notes
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QAE results
Right ear
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Refer
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Left ear
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Pass
Refer
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Capture notes for tympanometry?
(*)
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No
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Tympanometry-Notes
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Pure-tone screening
Right ear
(*)
Pass
Refer
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Left ear
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Pass
Refer
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Capture notes for Pure-tone screening?
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No
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Pure-Tone-Notes
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Referal of patient and Summary of consult
Did you refer the patient?
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Hearing Aid Required?
(*)
Yes
No
Please indicate whether a hearing aid is needed or not!
Reason / Summary of consultant
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AntiSPAM Measure
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