Audiology Appointment Request
Child Information
Today's Date
Child's First Name
Child's Last Name
Date of Birth
Language spoken at home
Parent or Legal Guardian
First Name
Last Name
Street Address
City
State/Province/Region
Zip/Postal Code
Country
Home Phone
Work Phone
Cell Phone
E-Mail Address
Referred by
Regional Center
Pediatrician
Teacher/School District
Friend
Other
Do you have any concerns about your child's overall development?
Yes
No
If yes, please explain
Describe your main concern about your child's hearing
Child's Hearing
What sounds do you think your child can hear?
Whispers
TV
Speech from a distance
Speech
Phone
Vacuum Cleaner
Airplanes
Doorbell
Banging objects
Does your child follow verbal commands?
Yes
No
If so, give an example
Is there history of childhood
hearing loss in the family?
Yes
No
If so, explain:
Does the child get
frequent ear infections?
Yes
No
How often? (times per year)
Describe Child's General Health:
Describe's Child General Health:
Good
Fair
Poor
List any health conditions
Birth History:
Full Term
Premature
List any complications at birth:
Does your child have any other diagnosed health problems, or developmental concerns?
Comments
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