Questionnaire - Newcastle Health Enterprise

Pre Screening Questionnaire

Please take a few minutes to complete this questionnaire. Your answers help our doctors determine if any extra tests or treatments are needed before your visit. After you submit it, you’ll be guided to complete your patient registration. Thank you for your time.

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
- snoring or sleep issues
- ear infections, hearing or speech
- tonsillitis
- large tonsils
- epistaxis (nose bleeds)
- swallowing issues
- breathing issues
- voice concerns
- behaviour concerns
- other
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
Max. file size: 256 MB.

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
- Rarely
- Softly some nights
- Loudly some nights
- Softly every night
- Loudly every night
** 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
- loudly every night.
- softly every night.
- loudly some nights
- softly some nights.
- rarely or never.
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
- Never
- Rarely
- Sometimes
- Often
- Always
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
- never
- rarely
- sometimes
- often
- always
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
- a “lump” in my throat
- a sore throat
- a persistant cough
- hoarseness or change in my voice
- difficulty swallowing (dysphagia)
- other
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
- constant
- intermittent
- periodic
- occasional
- rare
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
- is too loud
- is too soft
- is harsh
- is hoarse
- is nasal
- has frequent pitch breaks
- is high pitched
- is low pitched
- is monotonous
- is difficult to control
- sounds breathy
- pitch wavers
- wavers in intensity
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?

Pre Screening Questionnaire

Paediatric Questionnaire

Tonsillitis

Ears Hearing & Speech

Adult Questionnaire

Adult Tonsillitis

Sinusitis

Snoring

Cough, Hoarseness & Dysphagia

Speech & Voice