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    Personal Information:















    YesNo


    YesNo

    Pregnancy History:




    Birth History:




    YesNo


    PassFailDon't Recall

    Medical History:


    High FeverSeizures/ConvulsionsPast/Present Medications


    YesNo


    Development and Social History:


    YesNo

    YesNo





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

    ExcellentGoodFairPoor

    ExcellentGoodFairPoor


    ExcellentGoodFairPoor

    Hearing History:


    YesNo

    YesNo


    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Ear History:


    YesNo



    YesNo

    YesNo

    YesNo

    YesNo

    YesNo



    YesNo

    Please arrive 15 minutes prior to your scheduled appointment time.