Fine Hearing Care INFANT HISTORY FORM
  Year Month Day
Child's Name: ______________________________ Today's Date:      
Male: _____     Female: _____ Date of Birth:      
Current Age:      
General Health Information:
Describe your child general health: GOOD FAIR POOR
Name of your pediatrician: __________________________________________
Name of other physicians that have seen your child: __________________________________________
Has your child taken recent medication(s)? YES NO What? ___________________
Current Hearing Information:
Do you feel that your child has a hearing problem?  YES NO
Has your child had a hearing screening? YES NO The Results? ____________
Does your child startle to loud sounds? YES NO
Does your child turn to sounds? YES NO
Does your child wear hearing aids? YES NO Since When? ____________
Does your child receive special services? YES NO What? __________________
During pregnancy, did the child's mother have: Which Trimester?
Any Illnesses, Accidents, Or Complications? YES NO 1st 2nd 3rd
Three Day Measles? YES NO 1st 2nd 3rd
German Measles? YES NO 1st 2nd 3rd
Rubella? YES NO 1st 2nd 3rd
A  Rash With Fever? YES NO 1st 2nd 3rd
CMV, Herpes, Syphillis, Meningitis, HIV? YES NO 1st 2nd 3rd
At birth, did the child have: 
Birth Weight Less Than 1500 grams (3.3 lbs.)? YES NO
Jaundice Or Hyperbiliruminemia? YES NO
Low Apgar Score? YES NO
NICU Care? YES NO How Long? ______________
A Ventilator For 5 Days Or Longer? YES NO
Any Physical Anomalies? YES NO Describe: _______________
After birth, did the child have?
Bacteria Meningitis? YES NO When? _________________
Problems With Sucking, Swallowing, Or Feeding? YES NO Describe: _______________
Head Trauma Or Unconsciousness? YES NO Describe: _______________
Change In Development? YES  NO Describe: _______________
Comments: ___________________________________________________________________________
_____________________________________________________________________________________

Copyright © 2006 Fine Hearing Care.
All rights reserved.
Please email comments or questions re: website to webmaster.