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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.