Pediatric Case History

SECTION I:

Child's Name*

First Last

Age*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Email*

Parent or Guardian Name*

First Last

Parent or Guardian Phone*

How was your child referred to this office?*

What insurance(s) do you have?*

Who is the beneficiary?*

What is his/her DOB?*

What is the name of your child's primary care physician?*

Do you want a copy of your child's hearing test sent to the physician?*

Yes
No

List any major health conditions your child may have*

List any medication your child is taking*

Were developmental milestones reached appropriately?*

Yes
No

If No, please explain

SECTION II:

Do you have any concerns about your child's hearing?*

Yes
No

If Yes, please explain

Has your child had any ear infections?*

Yes
No

If Yes, how many and when was the last one?

Does your child have ringing in the ears?*

Yes
No

Has your child had sudden hearing loss in one or both ears?*

Yes
No

Does your child have any dizziness or vertigo?*

Yes
No

Does your child have any ear pain?*

Yes
No

Is there a family history of hearing loss?*

Yes
No

Has your child had exposure to loud sounds or noise?*

Yes
No

Has your child had any ear surgeries?*

Yes
No

Are there any other concerns about your child's hearing that you would like to discuss with the audiologist today?*

By submitting this form, you are agreeing that you have read and understood our Privacy Policy.

Phone*

Email

This field is for validation purposes and should be left unchanged.

SECTION I:

SECTION II:

Sign Up Today