Patient Questionnaire • Ear Nose Throat Newcastle

I am*

the patient
the parent of a paediatric patient

(a paediatric patient is classified as under 16 years old)

Best email address for correspondence:

I have an initial appointment with Dr Jefferson or Professor Winters at ENT Newcastle*

Yes - Dr Niall Jefferson
Yes - Prof Ryan Winters
No appointment date yet

I have been treated previously by Dr. Jefferson/AProf Winters. (privately or through the public system)*

Yes
No

Please list any family members who are patients at ENT Newcastle.

Paediatric Questionnaire

Child's Name*

First Last

Child's Date of Birth*

Child's Medicare Number

Medicare individual reference number

Name of parent/guardian filling out this form*

First Last

The main reason(s) for the referral of my child is(are)

tick any that apply

Please describe the reason for your child's referral in your own words:

My child has been previously diagnosed with

tick any that apply

Asthma
Diabetes
Allergic rhinitis
Eczema
Behavioural Issues (ADD/ADHD etc)

My child develops tonsillitis

7 times or more in the past 12 months
5 times a year for the past 2 years
3 times per year for the past 3 years
less than this

Tonsillitis

My child's first episode of tonsillitis occured at age

My child has developed recurrent tonsillitis

For the past year
For the past 2 years
For the past 3 years
For 4 or more years

My child requires antibiotics during episodes of tonsillitis

Rarely
Sometimes
Always

Due to tonsillitis, my child has

tick any that apply

Time off school or work
Quinsy (abscess in the mouth)
Aphthous ulcers (ulcers in the mouth)
Tonsil stones
Difficulty breathing or sleeping
Required multiple treatments of antibiotics

My child has an immediate family memeber that required a tonsillectomy and /or adenoidectomy

tick any that apply

No
Yes - sibling
Yes - parent
Unsure

My child experiences nose bleeds

Yes
No

My child experiences nose bleeds

more than once a day.
more than once a week.
more than once a month.
less frequently than this.

I have concerns about my child's

tick any that apply

ears (e.g. pain or infection).
hearing.
speech.
none of these.

Ears Hearing & Speech

My child has an immediate family member who has had grommets placed in the ears

Yes
No
Unsure

My child has had ear infections in the past 12 months

No
Yes 3 or more in the past 6 months
Yes 5 or more in the past 12 months
Less than this

My child has had an ear perforation (a hole in the ear drum) in the past 12 months.

No perforations
Yes 1-2 perforations in the past year
Yes 2-4 perforations in the past year
Yes 5 or more

I have been told my child has a delay in his/her speech and language development

Yes
No

My child is currently receiving speech therapy.

Yes
No

Hearing Assessment

Based on your answers, Dr Jefferson suggests your child undergo a hearing assessment prior to your appointment with him.

My child has had a recent hearing test (with the past 6 months)
My child has not had a recent hearing test (within the past 6 months)

Audiology Report

Please attach and upload audiogram here. You may also email us a copy at admin@entnewcastle.com.au or bring it with you to your appointment. If a recent audiogram was sent through with your referral please disregard.

My child

tick any that apply

is a restless sleeper
gets hot and sweaty at night
wakes multiple times at night
seems tired in the morning
wets the bed at night frequently

My child snores

** if relevant, please bring a video or audio recording of your child snoring to your appointment **

I have noticed sleep apnoea episodes (pauses in breathing while sleeping) by my child.

Yes
No

My child seems to breathe through

the nose most of the time.
the mouth most of the time.
I haven't noticed.

My child seems to avoid foods that require a lot of chewing.

Yes
No
I haven't noticed

My child has sensory issues.

Yes
No

Briefly describe your child's sensory issues.

My child seems to always be congested.

Yes
No

We have trialled a nasal steroid for 6 weeks.*

Avamys, Nasonex, Rhinocort or similar

Yes, with some improvement
Yes, with no improvement
No, we haven't trialled a nasal steroid

I am concerned about my child's behaviour.

Yes
No

My concerns are

My child is currently taking medication.

Yes
No

Please list medications

Is there any additional information you'd like our Clinical Staff to be aware of, or any specific questions you would like answered at your appointment?

Adult Questionnaire

Name*

First Last

Your Date of Birth*

Your Medicare Number

Medicare individual reference number

I have been previously treated for Ear Nose Throat issues.

yes
no

Briefly indicate which ENT doctor and any previous treatments.

The main reason(s) for my referral is/are

tick any that apply

Nasal Congestion, Sinusitis or Snoring
Tonsillitis
Epistaxis (nose bleeds)
Exostosis "surfer's ear"
Cough, Hoarseness or Dysphagia (swallowing issues)
Speech and Voice concerns
Other

In your own words, please explain the reason for your referral.

I have had trauma to my nose in the past.

yes
no

I have been experiencing nose bleeds

more than once a day.
more than once a week.
more than once a month.
less than this.

I have a history of nasal allergies.

yes
no

Please list known allergies.

I have high blood pressure.

Yes
No
Unsure

I take the following herbal preparations.

tick any that apply

Ginger
Ginseng
Fish Oil
Ginko
Tumeric
Garlic
None of these

I smoke.

Yes
No

My nose has become increasingly blocked on the affected side.

Yes
No
Unsure

I have noticed changes to my vision (e.g. double vision).

Yes
No

Due to my nose bleeds I have

visited my GP.
presented to emergency at hospital.
had my nose cauterized.
had my nose packed.

Adult Tonsillitis

I have had tonsillits

7 or more times in the last year.
5 times a year for the past 2 years.
3 times a year for the past 3 years.
less than this.

I require antibiotics during episodes of tonsillitis

Always
Sometimes
Rarely

I experience fevers when I have tonsillitis

Always
Sometimes
Rarely

I have had the following complications due to tonsillitis

tick any that apply

Time off school/work
Quinsy (abscess in the mouth)
Aphthous ulcers (ulcers in the mouth)
Tonsil stones
Difficulty breathing
Difficulty sleeping
Difficulty swallowing

I get sinusitis

rarely or never
for a few weeks each year
2-3 months per year
more than 3 months per year

Sinusitis

I have had sinus issues

for 5 or more years
for the past 2-5 years
just in the past year
I do not have sinus issues

My sinusitis symptoms include

tick any that apply.

facial pain or pressure.
nasal discharge.
nasal obstruction or congestion.
fever.
dental pain.
headaches.
change in vision or double vision.
nosebleeds.

I have trialled a sinus rinse in conjunction with a nasal steroid.

Sinus Rinse: Flo, FESS or NeilMed or similar Nasal Steroid: Avamys, Nasonex or similar.

yes, with some improvement.
yes, with no improvement.
no, I have not trialled a sinus rinse in conjunction with a nasal steroid.

I trialled the sinus rinse with nasal steroid

daily for a few days.
daily for more than 4 weeks.
occasionally for a few days.
occasionally for more than 4 weeks.

I have had a scan of my head or sinuses within the past 12 months.

Yes
No

Snoring

I snore

I have been told my snoring can be heard

only in the room.
through a closed door.
on the other side of the house.
unsure.

Others are bothered by my snoring

yes
no

In the morning I wake feeling

tired and fatigued most days.
tired and fatigued some days.
well rested.

Others have noticed pauses in my breathing during sleep (apnoea episodes)

Yes
No
Unsure

I have high blood pressure

Yes
No
Unsure

I have trouble sleeping

During sleep I

tick any that apply

am restless
choke or struggle for breath
get hot and sweaty
wake frequently

I wake with headaches

rarely or never
sometimes
often

I have used a CPAP device

Yes, I find it helpful
Yes, it was not helpful
No, but willing to trial
I do not wish to trial

I feel like my nose is congested or blocked

My nose feels blocked or congested

more on my right side
more on my left side
evenly on both sides

I have trialled a nasal steroid for my blocked or congested nose.

Avamys, Nasonex or similar.

Yes, with some improvement.
Yes, with no improvement.
No, I have not trialled a nasal steroid.

I wish to change the external appearance of my nose.

Yes
No

Cough, Hoarseness & Dysphagia

My main issue is

Please explain "other"

It has been an issue for

weeks
months
years

My issue

tick any that apply

comes and goes
constantly bothers me
has been getting worse
fully recovers in between episodes
never completely resolves

I have experienced pain in or around my throat

yes
no

I

have never smoked
smoked tobacco in the past
currently smoke

How many years did you smoke?

How long have you been a smoker?

I would smoke about

1-10 cigarettes per day
10-20 cigarettes per day
more than 20 per day

I have noticed (or others have commented) that I clear my throat quite often.

yes
no
unsure

I drink water regularly thoughout my day

yes
no

I experience reflux

rarely or never
sometimes
often

I take an anti-reflux medication

yes
no

I have been taking anti-reflux medication for

less than 3 months
more than 3 months

The anti-reflux medication I take is

I find that the anti-reflux medication I take

helps with my symptoms
doesn't help much with my symptoms

My cough is productive (I cough up phlegm)

Yes
No

I have coughed up blood recently

Yes
No

I drink alcohol

rarely or never
occasionally
most days

In the last few months I have had unexplained weight loss

yes
no

Speech & Voice

I have had trauma to the head or neck in the past

yes
no

Please describe trauma.

I have been intubated in the past (had a breathing tube placed)?

yes
no

I am seeing or have seen a speech therapist or a vocal coach in the past.

yes
no

Who did you see (or are you currently seeing)?

Do you have any family members with speech or voice issues?

yes
no
unsure

At home I speak

English only
English and another language
a language other than English

Please describe your voice in your own words.

The issue with my voice is

My issue

came about gradually
came on suddenly

Things that make my voice worse

tick any that apply

smoke
reflux
overuse
other

Other things that make my voice worse

Things that seem to help my voice

rest
hydration
other

Other things that help my voice

My voice

tick any that apply

In the past month I have experienced

hoarseness
clearing the throat
excess throat mucus or post nasal drip
difficulty swallowing food, liquid or pills
coughing after eating or lying down
breathing difficulty or choking episodes
anoying cough
a sensation of something stuck or a lump in my throat
heartburn, chest pain, indigestion or stomach acid coming up

tick any that apply

My voice is most affected

tick any that apply

at the start of the day
at the end of the day
when tired
when singing
after shouting or crying
when I am stressed
other

Other times my voice is affected

I complain of a sore neck

often
sometimes
rarely or never

I complain of a blocked nose

often
sometimes
rarely or never

I regularly use my voice for

tick any that apply

shouting
screaming
singing
whispering

I often

tick any that apply

cough
clear my throat
sneeze

Are you aware of any family history of emotional issues?

yes
no
unsure

Please describe any family history of emotional issues.

Do you have any pets at home?

yes
no

Please list pets

Please list any periods of past hospitalizaion & approx dates & reason.

Please list any prescription medication in the past year.

I am currently taking medication

yes
no

Current medications

Is there any additional information you'd like our Clinical Staff to be aware of, or any specific questions you would like answered at your appointment?

New Questionnaire

Paediatric Questionnaire

Tonsillitis

Ears Hearing & Speech

Adult Questionnaire

Adult Tonsillitis

Sinusitis

Snoring

Cough, Hoarseness & Dysphagia

Speech & Voice