To download a PDF of this form, please CLICK HERE! Personal Information: Infant's Name * Date of Birth * Mother's Name * Father's Name * Phone # * Email * Siblings (Names & Ages) * Info Provided By * Relationship to Child * What location are you visiting? * AmherstWilliamsvilleOrchard ParkTonawanda Background Information: Do you have concerns regarding your baby’s hearing? * YesNo If so, please describe: Did your baby receive a newborn hearing screening? * YesNoDon't Recall If so, what were the results? PassedFailed Has your baby received any other evaluations since birth? * YesNo If yes, please list: Is there a family history of hearing loss? * YesNo Does your baby startle/respond to loud sounds (eye blink, cry, head turn)? * YesNo Pregnancy History and Birth history: Length of Pregnancy (full term, premature, late): * Complications during pregnancy: * Medications/drugs used during pregnancy: * Alcohol used during pregnancy (how often): * Birth weight: * APGAR score (if known): * Was your child in intensive care? * YesNo If yes, reason & length of stay: Other delivery complications: * Please list any medical conditions your baby has: * Please list any medications your baby has received since birth: * Other Important Information Not Provided Above: * Please arrive 15 minutes prior to your scheduled appointment time.