To download a PDF of this form, please CLICK HERE! Personal Information: Child's Name * Date of Birth * Mother's Name * Father's Name * Phone # * Email * Siblings (Names & Ages) Info Provided By * Relationship to Child * Who referred you to our office? * Primary Care Physician * What location are you visiting? * AmherstWilliamsvilleOrchard ParkTonawanda What is your chief concern? * HearingSpeech/Language DevelopmentOther Is there a family history of hearing loss? * YesNo If yes, who? Does your child currently receive speech therapy? * YesNo If yes, how many times per week? Pregnancy History: Complications during pregnancy: * Medications/drugs used during pregnancy: * Alcohol used during pregnancy (how often): * Birth History: Birth weight: * How many weeks early/late: * Was your child in intensive care? * YesNo If yes, reason & length of stay: Newborn Hearing Screening: * PassFailDon't Recall Other delivery problems: * Medical History: Has your child experienced any of the following? High FeverSeizures/ConvulsionsPast/Present Medications If yes, explain: Hospitalizations/Surgeries? * YesNo If yes, explain: Medical Conditions: * Development and Social History: Does your child interact well with others his/her age? * YesNo Does your child have behavioral problems? * YesNo What age did your child sit alone? * What age did your child walk alone? * What age did your child use 1st word? * What age did your child use 1st sentence? * Describe any slowly developing behavior: * Keeping your child’s age in mind, please rate the following: Motor coordination and balance * ExcellentGoodFairPoor Ability to keep attention on activity * ExcellentGoodFairPoor Ability to follow directions * ExcellentGoodFairPoor Ability to speak clearly * ExcellentGoodFairPoor Hearing History: Do you now or have you ever had any concerns about your child’s hearing? * YesNo Does your child have a permanent hearing loss that you are aware of? * YesNo If so, please describe (ex. 1 ear only, can’t hear high pitches, etc.): Has a teacher ever expressed concern about your child’s hearing? * YesNo Does your child respond to sound consistently? * YesNo Do you feel you need to repeat things for your child in order to be understood? * YesNo Does your child say "What?" or "Huh?" frequently? * YesNo Do you need to raise your voice for your child to respond? * YesNo Does your child sit close to the TV or turn up the volume? * YesNo Does your child appear to have difficulty understanding speech in background noise? * YesNo Ear History: Has your child ever had an ear infection? * YesNo How many? * Most recent: * Has your child ever been treated with antibiotics for an ear infection? * YesNo Is your child currently on antibiotics for treatment or prevention of ear infections? * YesNo Has your doctor ever observed fluid behind your child's eardrums? * YesNo Has your child ever seen an Ear, Nose, & Throat (ENT/Otolaryngologist) specialist? * YesNo Has your child ever received pressure equalizing tubes for chronic ear infections? * YesNo How many sets of tubes? * At what ages? * Does your child have frequent colds, allergies, or congestions? * YesNo Other Important Information Not Provided Above: * Please arrive 15 minutes prior to your scheduled appointment time.