Access Audiology Self-Referral

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

Initial Questions

Are you over 50 years old?: *

Have you noticed any problems with your hearing?: *

Are you concerned or worried about your hearing difficulties?: *

Would you be prepared to consider using hearing aids?: *

You are not eligible for this service

You are unable to continue: *

Processing

Have you experienced

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 (nausea, swaying or floating sensations) 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.: *

Have you had NHS hearing aids supplied in the last three years?: *

Thank you for completing the survey.

Your answers have shown that you are eligible to self-refer to the local audiology service.

Please now get in touch with your provider of choice via telephone, or online to arrange next steps.
No further action will be taken unless you contact your provider of choice.

If you think that you have ear wax, please discuss this with your provider of choice.

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.

Providers

You do not need to submit this form, and need to contact one of the providers: *

You will not eligible for the Community Adult Hearing service and should make an appointment with your GP.

If you wish to inform the surgery of any of the symptoms please continue with this form.

Should you have a hearing test and be fitted with a hearing aid(s), the provider will manage your aftercare and review appointments.

Typically, at the end of three years, you can be offered a new full reassessment and be offered choice of provider.
Your existing provider will help with this.

You do not need to submit this form, and need to contact your provider: *

Processing

Personal Details

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.

Access Audiology Self-Referral

Thank you for completing the survey.

Providers

You will not eligible for the Community Adult Hearing service and should make an appointment with your GP.

Privacy Consent

HEYSHAM PRIMARY CARE CENTRE

MORECAMBE HEALTH CENTRE

WEST END MEDICAL PRACTICE

YORK BRIDGE SURGERY

WESTGATE MEDICAL PRACTICE

CQC RATING

Functional Cookies

3rd Party Cookies