Health Information Sheet-Ear Health Formhistory Page 2
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1
2EAR HEALTH HISTORY
CHILD’S NAME_______________________ DOB___________ DATE__________
INFORMATION_____________________________ CHILD’S AGE ____________
Please help us better understand your child by answering the following questions:
1. Does your child have normal hearing (when ears are clear and healthy)?
_____________________________________________________________________
2. Did your child ever have any ear infections?____________If so, how many total?
Between birth to 1 year old _____________ 3 to 4 years old __________
1 to 2 years old _____________ 4 to 5 years old __________
2 to 3 years old _____________ 5 + years _______________
How long did the ear infections last?_______________________________
How often did they re-occur?_____________________________________
3. Has your child had myrongotomies and PE tubes inserted? ______________
If so, how many times and at what ages? __________________
4. Has your child received speech/language therapy? _________________
If so, at what ages and for how long? _____________________
Therapy was for ______________ articulation, ________________________
language or other______________ (Please explain ____________________)
5. Has your child received amplification during periods of not hearing?
_____________________________________________________________________
6. Is there anything else in your child’ ear health history that may be
helpful in understanding your child’s educational needs?
_____________________________________________________________________
7. What concerns do you have about your child and school? ____________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
from Davis, Dorinne. Otitis Media: Coping with the effects in the
Classroom. Hear You Are, Inc.: Stanhope, NJ, 1989.
Permission to copy this form was given by Dorinne Davis, “Otitis Media: Coping
with the Effects in the Classroom. Hear You Are, Inc.: NJ, 1989
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