Pediatric History Form

Fine Hearing Care PEDIATRIC HISTORY FORM


Child's Name: ______________________________	Today's Date:
Male: _____ Female: _____	Date of Birth:
	Current Age:
What concerns brought you here today? ______________________________________________________
_____________________________________________________________________________________

General Health Information:
Describe your child's general health:	GOOD	FAIR	POOR
Name of your pediatrician:	__________________________________________
Name of other physicians that have seen your child:	__________________________________________
Were there any complications at birth?	__________________________________________
What significiant illnesses has your child had?	__________________________________________
Has your child taken recent medication(s)?	YES	NO	What? _______________________

Current Hearing Information: Does your child…
Have an identified hearing loss?	YES	NO	Describe: _____________________
Startle to loud sounds?	YES	NO
Turn to softer sounds?	YES	NO
Respond to his/her name?	YES	NO
"Hear what he/she want to hear"?	YES	NO
Have hearing that seems to fluctuate?	YES	NO
Intently watch the speaker's face to listen?	YES	NO
Wear hearing aids?	YES	NO	Since when? ___________________
Receive special services? (Speech, OT, PT, etc.)	YES	NO	What? _______________________
Have vision problems?	YES	NO	Describe: _____________________
Have a history of ear infections or ear aches?	YES	NO	How recent? ___________________

Did your child have a hearing screening at birth?	YES	NO	Results? ______________________
Has your child ever been seen by an ear doctor?	YES	NO	Who? ________________________
Has your child ever had tubes placed in his/her ears?	YES	NO	How many times? ______________
			When? ______________________
Current Speech and Language Information:
Are there concerns about your child's speech skills?	YES	NO	What? ______________________
What language(s) are used at home?	__________________________________________
How are wants/needs expressed?	__________________________________________

Family and Social Information:
Any family members with hearing loss?	YES	NO	Who? ________________________
Any family members with speech problems?	YES	NO	Who? ________________________
Any family members with learning problems?	YES	NO	Who? ________________________
Any siblings?	YES	NO	Ages: ________________________
Comments: Please feel free to write comments on back of this page if needed.