Audiology Appointment Request

Hearing testing is only for children birth through five years old in the southern California area

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

Do you have any concerns about your child's overall development?

Yes

If yes, please explain If yes, please explain

Describe your main concern about your child's hearing

Child's Hearing

Does your child follow verbal commands?

Yes

If so, give an example

Is there history of childhood
hearing loss in the family?

Yes

If so, explain:

Does the child get
frequent ear infections?

Yes

How often? (times per year)

Describe Child's General Health:

Describe's Child General Health:

Good

Fair

Poor

List any health conditions 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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Whispers	TV	Speech from a distance	Speech	Phone	Vacuum Cleaner
Airplanes	Doorbell	Banging objects