| 716-833-4488 |
| Amherst |
| Williamsville |
| Orchard Park |
| Tonawanda |

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Pediatric Hearing Health History Form

Patient Forms > Hearing Forms > Pediatric Hearing Health History Form

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? *

What is your chief concern? *

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

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.

Amherst
Williamsville
Orchard Park
Tonawanda
716-833-4488

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