Dizziness/Vertigo for Vestibular Audiology Assessment Only
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
Adult
- Hearing loss with associated neurological signs
- Sudden / Rapid onset unilateral or bilateral hearing loss
(direct phone contact with the ENT registrar on call to discuss the case and arrange review as clinically appropriate)
Paediatric
- Paediatric Hearing loss
- Sudden loss or deterioration
- Paediatric Otitis media
- Any suspicions Mastoiditis (proptosis of pinna), meningitis or other complication of ASOM
- Trauma
- New onset facial nerve palsy
- Other referrals to emergency not covered within these conditions (Paediatric)
- Foreign body
- ENT conditions with associated neurological signs e.g. facial nerve palsy, profound vertigo and/or sudden deterioration in sensorineural hearing
- Acute and/or complicated mastoiditis
- Auricular haematoma
- Significant head injury
- Congenital abnormality of the head/neck
- Meningitis/encephalitis
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| Category 1 (appointment within 30 calendar days) |
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| Category 2 (appointment within 90 calendar days) |
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| Category 3 (appointment within 365 calendar days) |
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Please insert the below information and minimum referral criteria into referral
1. Reason for request Indicate on the referral
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
2. Essential referral information Referral will be returned without this
- Description of:
- onset, duration, frequency, and quality
- functional impact of dizziness
- any associated otological/neurological symptoms/history
- treatment to date and efficacy
- Investigation/imaging results
- Diagnostic audiology assessment (where available and not cause significant delay)
3. Additional referral information Useful for processing the referral
- History of any of the following:
- cardiovascular conditions
- neck conditions
- neurological conditions (e.g., stroke, TIA, vertebro-basilar artery insufficiency, migraine)
- autoimmune conditions/diabetes
- eye conditions (e.g., blindness, retinal detachment, cataract surgery, ophthalmoplegia, strabismus)
- previous head injury
- psychological history (anxiety and/or claustrophobia etc.)
- drug and alcohol use
- Current medication list
- Previous treatment with vestibulo-toxic / ototoxic medications (e.g. gentamycin, cisplatin)
4. Request
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Patient's Demographic Details
- Full name (including aliases)
- Date of birth
- Residential and postal address
- Telephone contact number/s – home, mobile and alternative
- Medicare number (where eligible)
- Name of the parent or caregiver (if appropriate)
- Preferred language and interpreter requirements
- Identifies as Aboriginal and/or Torres Strait Islander
Referring Practitioner Details
- Full name
- Full address
- Contact details – telephone, fax, email
- Provider number
- Date of referral
- Signature
Relevant clinical information about the condition
- Presenting symptoms (evolution and duration)
- Physical findings
- Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
- Body mass index (BMI)
- Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
- Current medications and dosages
- Drug allergies
- Alcohol, tobacco and other drugs use
Reason for request
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
Clinical modifiers
- Impact on employment
- Impact on education
- Impact on home
- Impact on activities of daily living
- Impact on ability to care for others
- Impact on personal frailty or safety
- Identifies as Aboriginal and/or Torres Strait Islander
Other relevant information
- Willingness to have surgery (where surgery is a likely intervention)
- Choice to be treated as a public or private patient
- Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
Last updated: 20 December 2021
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