Fillable Diagnostic Hearing Evaluation Form printable pdf download

Use this version for patients born on or after January 1, 2014

SPEC#____________________

NBHS use only

Diagnostic Hearing Evaluation Form

Department of Health, Children’s Medical Services (CMS), Newborn Screening Program

*Audiology Clinic _______________________________________________*Phone Number_____________________*Date of Visit__________

Demographic Information (Items with an asterisk * are required) PLEASE PRINT

*Child’s Name

*Child’s DOB

*Gender

*Street Address

*Multiple Birth Order

*City

*Zip

*Mother’s Name at Baby’s Birth

*County

*Home Phone

*Mother’s Social Security Number

*Alternate Phone #/Email

*Birth Hospital

*Primary Language of Family

*Child resides with

*Primary Care Physician

*Physician Phone

*ICD9 code(s) (required for hearing loss only)

Physician Fax

Audiological Evaluation Results:

Level 1 - Diagnostic evaluation results from this visit (Please record Pass (P) or Fail (F)):

Diagnostic

Bone Cond

Tone Burst

Steady State

Diagnostic

High Freq

Middle

ABR

ABR 500

ABR 1000

ASSR

OAE

Immittance/

Ear Muscle

Tympanogram

BOA

VRA

Reflex

Right Ear

__ P __ F

Left Ear

__ P __ F

Level 2 – Type and degree of hearing loss suspected (S) or confirmed (C) during this visit:

None

Slight

Mild

Moderate

Moderately

Severe

Profound

Sensori-

__Permanent

Auditory

__Temporary

-10-15

16-25 dB

26-40 dB

41-55 dB

Severe

71-90

> 91 dB

Neural

Dyssynchrony

Conductive

Mixed

56-70 dB

Right Ear

__S __C

Left Ear

__S __C

*Referral and Follow-Up Information

Overall Hearing Status (select one):

Hearing risk status – Check all that apply:

___ Apparent normal hearing in both ears at this time

_____

Family history

___ Apparent middle ear dysfunction; return on ________________

_____

PPHN

DD/MM/YY

_____

ECMO

___ Inconclusive or borderline results; return on ________________

DD/MM/YY

_____

Exchange transfusion for hyperbilirubinemia

___ Medical complications prevent hearing testing until age ____ months

_____

Birth weight less than 1500 grams

___ No show/cancelled appointment scheduled for________________

_____

NICU

DD/MM/YY

___ Permanent hearing loss has been confirmed during this visit.

Comments: (i.e. late onset loss, malformations, further referral, etc.)

____________________________________________________________________________________________________________________________

FAX Form to (850) 245-4049 within 2 DAYS OF THE APPOINTMENT

*Audiologist’s name: ______________________________________

*Audiologist Address:

Street

Suite

City & State

ZIP

Please return this form by secure email, mail or by fax (850) 245-4049 to the FL Dept. of Health, Children’s Medical Services, Newborn Screening Program, which is located at 4052 Bald Cypress Way Bin A-06

Tallahassee, Florida 32399-1707. If you need assistance completing or submitting this form, contact the Newborn Screening Program toll free at (866) 289-2037.

Revised

Diagnostic Hearing Evaluation Form

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