Eform Instance
API endpoint for querying EForms
GET /api/public/eforms/30/?format=api
{ "url": "https://testing.clinic-frontend.dc.gompels.com/api/public/eforms/30/?format=api", "is_deleted": false, "deleted_at": null, "name": "Microsuction - Pre Appointment Form", "title": "Microsuction - Pre Appointment Form", "description": "Microsuction - Pre Appointment Form", "version": 1, "subversion": 1, "formDefinition": [ { "id": "header-e0e557f6-e4f8-4d32-9a74-4390f1a6b172", "name": "header-16676f7c-9bd6-42dd-b20f-8ad95b1bcea8", "type": "header", "label": "Current Symptoms", "access": false, "subtype": "h1" }, { "id": "paragraph-c1b134d4-fc98-4a54-ad07-24f82b4dcbde", "name": "paragraph-e8c64691-305a-4a38-9bfe-8f2e5ed1b530", "type": "paragraph", "label": "Do you have, or have you ever had: ", "access": false, "subtype": "p" }, { "id": "checkbox-group-8ba90b42-b36f-42d3-91b6-91ae6ef87887", "name": "perforated_ear_drum", "type": "checkbox-group", "label": "Perforated ear drum (a hole in the ear drum)?", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-1888912b-2318-4473-9002-d4fadd408147", "name": "hearing_loss", "type": "checkbox-group", "label": "Hearing loss either from wax build up or otherwise ? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-7354f502-ff3c-4855-b384-0595b1516174", "name": "ear_pain", "type": "checkbox-group", "label": "Ear pain? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-4124591d-3329-43db-a309-3ff49571f91b", "name": "tinnitus", "type": "checkbox-group", "label": "Tinnitus (Persistent ringing or buzzing noise in the head or ears)? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-d75c0260-f36b-44f3-b05e-b7b14ada7d4d", "name": "vertigo", "type": "checkbox-group", "label": "Vertigo (the sensation that you are moving or spinning)? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-51941d41-e5d4-4f35-8c60-ed0e32f7d3c9", "name": "ear_discharge", "type": "checkbox-group", "label": "Discharge from the ear(s)? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-dc5e2b46-227d-428d-b0be-ccbce8dd5f0f", "name": "ear_itchiness_irritation", "type": "checkbox-group", "label": "Itchiness/irritation of the ear(s)? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "paragraph-6503a813-7a81-447a-8dfa-b1048c78f2c1", "name": "paragraph-ef784722-83f1-456f-9de6-5df8cacefe4d", "type": "paragraph", "label": "Have you previously had:", "access": false, "subtype": "p" }, { "id": "checkbox-group-e2a9b6aa-983c-4a88-a887-7c5290808591", "name": "history_perforated_ear_drum", "type": "checkbox-group", "label": "Perforated ear drum (a hole in the ear drum)?", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-5344d53a-d887-412a-b696-6056b852cf8c", "name": "history_tinnitus", "type": "checkbox-group", "label": "Tinnitus (Persistent ringing or buzzing noise in the head or ears)? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-469d0568-c693-490b-895f-21e15a4caa48", "name": "history_vertigo", "type": "checkbox-group", "label": "Vertigo (the sensation that you are moving or spinning)? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-67dc2f41-c585-43a6-bdef-561daf534fb0", "name": "90_days_ear_infection", "type": "checkbox-group", "label": "Ear Infection in the last 90 days? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-823f5d14-f3ba-43ec-928b-483c389f419c", "name": "attempt_self_wax_removal", "type": "checkbox-group", "label": "Tried to remove wax yourself? If yes, explain how", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "text-88756e4a-09c0-455c-996d-04979103b7b4", "name": "wax_self_removal_detail", "type": "text", "label": "Self Removal of Wax detail ", "access": false, "subtype": "text", "required": false }, { "id": "checkbox-group-f47ccba1-b2be-4341-bd45-537798eebcb6", "name": "ear_operation_history", "type": "checkbox-group", "label": "Ever undergone an operation on your ears? If yes, please provide information of your operation below:", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "text-6b026c2b-c526-4db8-8759-6806791e552c", "name": "ear_operation_detail", "type": "text", "label": "Ear operation detail", "access": false, "subtype": "text", "required": false }, { "id": "checkbox-group-c119641d-695c-4597-84d9-208c832e95df", "name": "checkbox-group-7f07fca6-0026-4b0a-94db-20129c3cd9bc", "type": "checkbox-group", "label": "Ever undergone an operation on your nose/throat? If yes, please provide information of your operation below:", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "text-46d0680d-8d03-4d59-bdad-63c5673989be", "name": "noes_throat_operation_detail ", "type": "text", "label": "Nose/Throat Operation Detail ", "access": false, "subtype": "text", "required": false }, { "id": "paragraph-94d17daa-08f5-43c7-9940-0fdf6ca0e7fc", "name": "paragraph-cee3675e-5dac-46db-9cd0-2666778ba82f", "type": "paragraph", "label": "Additional Health History", "access": false, "subtype": "p" }, { "id": "checkbox-group-5b651573-69e4-4f54-ba79-965ee144792d", "name": "is_diabetic", "type": "checkbox-group", "label": "Are you diabetic?", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-5c277e85-5c37-4c84-b6ec-3ed9ea432c0d", "name": "takes_blood_thinners", "type": "checkbox-group", "label": "Do you take anticoagulant medication (blood thinners)?", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-4e50b5a4-d053-4345-a287-b85a71c5e188", "name": "takes_platelet_medicaiton", "type": "checkbox-group", "label": "Do you take antiplatelet medication (aspirin, clopidogrel, ticagrelor)? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "paragraph-e7da37e2-e582-4b9b-a771-64d7d86143d9", "name": "paragraph-0de4d8eb-17c8-42e2-afac-4bdd5da8c298", "type": "paragraph", "label": "Treatment History", "access": false, "subtype": "p" }, { "id": "checkbox-group-b36a991e-f79d-4c3d-ac4e-e28749ddaec5", "name": "seeing_ent_consultant_or_other", "type": "checkbox-group", "label": "Are you currently being seen by an ENT consultant or receiving treatment regarding your ears? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-dfecbefa-b916-40e8-886e-e973180dedf6", "name": "previous_microsuction", "type": "checkbox-group", "label": "Have you had microsuction ear wax removal before? If yes, any problems? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "text-f3c7ca57-20a6-42d0-b189-fd514e43d689", "name": "history_microsuction_problems", "type": "text", "label": "Detail of previous Microscution Problems", "value": "", "access": false, "subtype": "text", "required": false }, { "id": "paragraph-03a395f1-7987-4d38-a649-bb9a20127d98", "name": "paragraph-45682c85-9318-4cd8-a965-3a703c3234f0", "type": "paragraph", "label": "Consent", "access": false, "subtype": "p" }, { "id": "checkbox-group-ed807208-b678-42b9-a645-a0d783945b9c", "name": "consent_microsuction", "type": "checkbox-group", "label": "Do you consent to the use of microsuction? (using suction to remove ear wax) ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-2b05ed5f-4434-4980-bdca-3850a72e6a5f", "name": "consent_irrigation", "type": "checkbox-group", "label": "Do you consent to the use of irrigation? (using water to flush the ear wax out) ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "checkbox-group-03850197-83e5-435d-ad6e-b2a81ba6c3e5", "name": "microsuction_reasons_not_to_proceed", "type": "checkbox-group", "label": "Are you aware of any reason why we should not proceed with microsuction? ", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false }, { "label": "No", "value": "option-2", "selected": false } ], "required": true }, { "id": "paragraph-ee41fcd3-9a18-4e21-9bea-2c653ab09399", "name": "paragraph-19df2e8d-8bdc-4ad3-923a-5522197ce7f9", "type": "paragraph", "label": "Disclaimer", "access": false, "subtype": "p" }, { "id": "paragraph-8411eb08-d333-403d-bbd8-8e12ca4bed49", "name": "paragraph-5846e1a8-911d-4fa0-908f-87b1a366da1b", "type": "paragraph", "label": "Wax removal via microsuction is one of the safest methods to remove ear wax. In addition, irrigation (using a gentle pulse of water to flush out ear wax) or probe removal may be undertaken if considered to be more appropriate by the clinician. Your ear wax removal will be performed by a trained clinician working to the protocols set out within British Society of Audiology Aural Care Guidance document (August 2019). ", "access": false, "subtype": "p" }, { "id": "paragraph-f37d16cb-390a-4899-802a-ca8e7fcdaff3", "name": "paragraph-caeb8d50-1ef1-4695-9203-f38ef24914cf", "type": "paragraph", "label": "Incidents during ear wax removal are uncommon, especially with microsuction. However, possible minor risks that can occur are deemed to be acceptable include small nicks to the ear canal which can result in minor bleeding, soreness, mild discomfort, and short-term ringing in the ear (tinnitus). To ensure that the risk of complication is minimal, it is essential that accurate past medical history is supplied to our clinicians. More serious risk to the ear or eardrum can occur if the client cannot remain still during the procedure. Clients should inform the clinician of any likely movements. ", "access": false, "subtype": "p" }, { "id": "paragraph-27fb2b86-e82f-46d9-938a-7350c5894f8b", "name": "paragraph-3d7ffdf5-8fac-4464-8f24-5bcc9a8a8b4d", "type": "paragraph", "label": "Further complications, side-effects and material risks inherent in the procedure include but are not limited to the incomplete removal of ear wax requiring a return visit (for severely impacted wax), persistent tinnitus, perforation of the eardrum, hearing loss and infection. To keep the risk of the infection to a minimum, all equipment used in the ear is sterilised or for single use. However, there is always a risk that infection may occur once out of the practitioner’s care. Please contact the clinician for a follow-up visit should you experience any discomfort or worrying symptoms. ", "access": false, "subtype": "p" }, { "id": "paragraph-104d8ccb-7cf8-4e97-bb79-594dd01fadbe", "name": "paragraph-c5b5452d-5335-41ef-a171-b62f2bf68a97", "type": "paragraph", "label": "The CE marked suction unit is designed to remove fluids from the airway or respiratory support system and infectious materials from wounds. It has been adapted to the use of aural microsuction. By agreeing to these terms and conditions, you accept that you have read and understood the possible complications that may occur and agree that the hearing specialist cannot be held responsible for them. ", "access": false, "subtype": "p" }, { "id": "paragraph-8b3f69db-669e-463a-8afe-083d0d0f3a17", "name": "paragraph-c8eceabc-e1ac-4c14-9a58-5f30d859727e", "type": "paragraph", "label": "The answers you provide will be stored securely and held as part of your case history. It will only be shared with other medical professionals (with your consent) where it helps with further assessment or treatment. It will never be used for marketing purposes, and it is held in accordance with GDPR (General Data Protection Regulation). ", "access": false, "subtype": "p" }, { "id": "checkbox-group-edcfeac8-fe82-4f64-8ffa-f66b6c72ff7b", "name": "microsuction_consent", "type": "checkbox-group", "label": "Please tick here to confirm that you've read, understood and consent to the above conditions", "other": false, "access": false, "inline": true, "toggle": false, "values": [ { "label": "Yes", "value": "option-1", "selected": false } ], "required": true } ], "created": "2024-02-14T07:39:04.538883Z", "modified": "2024-02-14T07:39:04.538898Z", "archived": false, "is_vaccination_form": false }