To download a PDF of this form, please CLICK HERE!
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
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.