Newborn Hearing Health History Form

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

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

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: *