Hearing Health History Form
ADVERTISEMENT
1
2Revised 04.2016
Hearing Health History
For use with KBH screens for children 5 years of age and older.
Children who have had multiple ear infections and periods of hearing loss are more likely to have
language, vocabulary, and listening difficulties. Some history is beneficial for a more complete evaluation.
Parent(s) or guardian(s), please provide the following information.
Child’s name: ________________________________________________Birthdate: _______________
Primary care physician: ________________________________________________________________
Yes
No
1. Did your child have any ear problems* before the age of 1?
____
____
2. Has your child ever had a draining ear?
____
____
3. Approximately how many ear problems has your child had in his/her life?
____
____
0-2
3-5
6-10
10 or more
4. Does your child tend to have 4 or more ear problems each year?
____
____
5. Has your child had an ear problem in the last 6 months?
____
____
6. Has your child ever had an ear problem that lasted 3 months or longer?
____
____
7. Has anyone related to the child had many ear problems?
____
____
8. Has your child ever been seen by an ear specialist?
____
____
If yes, what doctor? ___________________________________
Month/year of last visit? _______________________________
9. Has your child ever had tubes placed in his/her eardrum?
____
____
If yes, how many times? _______________________________
At what age(s)? ______________________________________
Which ear? _________________________________________
10. Are you concerned about your child’s hearing?
____
____
11. Please mark all that apply to your child:
chicken pox
head injury
meningitis
episode of high fever
other serious health condition such as cancer
Please describe the condition: ____________________________________
____________________________________________________________
* Ear problem = ear infection, earaches, draining from ears, medicine taken for ears, fluid behind the
eardrum, hole in eardrum, etc.
R
.
EFERRAL IS REQUIRED IF A CHILD ANSWERS YES TO ANY ONE INDICATOR ON AN INITIAL HEARING PAPER SCREEN
Screener: ___________________________________________________ Date: __________________
PLEASE NOTE PROVIDERS ARE REQUIRED TO INTERPRET
AND INITIATE CARE WHEN INDICATED.
Excerpted from Hearing Screening Guidelines and Resource Manual (January 2004)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical