Pediatric Hearing Health History Form - Hearing Evaluation Services of Buffalo, Inc.

Pregnancy History:

Birth History:

Medical History:

Has your child experienced any of the following?
High FeverSeizures/ConvulsionsPast/Present Medications

Development and Social History:

Keeping your child’s age in mind, please rate the following:

Hearing History:

Ear History:

Is your child currently on antibiotics for treatment or prevention of ear infections? *
YesNo

It's Good to Hear