Infant Hearing Program Hospital Screening Form
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1North Bay Regional Health Centre
Infant Hearing Program
Hospital Screening Form
Please complete one form for every baby
Last name, First name
Date of birth (yyyy / mm / dd)
Patient Log #
Gestational Age (wks)
Serial #
Service Language
English
French
Female
Male
_________
430115
Parent / Legal Guardian (Last name, First name)
Residential Address (number, street, apartment, city, postal code)
Home telephone number
Cell / Secondary telephone number
Primary Care Physician (Last name, First name)
Midwife
No
Yes
ADMISSION TYPE (location)
Well Baby
NICU or Special Care Nursery
AT RISK FOR HEARING LOSS
No/ Unknown
Yes (If yes, Type of risk must be completed)
Family History:
IVH Intraventricular Hemorrhage Grade III or IV
a parent or a sibling ONLY with permanent hearing loss identified ≤ age 10
PVL Periventricular Leukomalacia
Baby’s mother / father Cause of hearing loss ____________________
ECMO Extracorporeal Membrane Oxygenation
Baby’s sister / brother
_______________________________________
HFO, HFJ High-frequency ventilation
Craniofacial Anomaly: cleft palate, malformed ear(s), other craniofacial anomaly
INO Inhaled nitrous oxide
Severe Hyperbilirubinemia: Kernicterus, Bilirubin 400 moI/L,
Birth Weight ≤ 1000g (2lb 3oz)
Exch
transfusion
Gestational age ≤ 30 weeks
5 minute APGAR ≤ 3
Cisplatin Chemotherapy mother
Severe Sepsis
Hearing Loss Syndromes: Alport , Branchio-Oto-Renal (BOR),
CHARGE, Crouzon, Down (Trisomy 21), Hunter, Osteogenesis
Proven meningitis
CMV Proven Cytomegalovirus Infection
Imperfacta (OI), Stickler, Treacher-Collins, Usher, Waardenburg,
Pendred, Enlarged Vestibular Aqueduct, LVA (EVA), Neurofibromatosis
Other proven TORCH infection: Herpes (HSV), HIV, Parvo B19, Rubella, Syphilis,
Toxoplasmosis, Varicella (VZV)
(NF2/ NFII)
Mondini Dysplasia
Severe Asphyxia/ Hypoxia
Other High Risk by Physician (reason)
PPHN Persistent Pulmonary Hypertension of the Newborn
_____________________________________________________
CDH Congenital Diaphragmatic Hernia
HIE Hypoxic-Ischemic Encephalopathy Sarnat 2 or 3
PARENT/LEGAL GUARDIAN GIVES CONSENT AND UNDERSTANDS that:
Yes
No
1. The Northeast Infant Hearing Program (IHP) will provide hearing screening for their infant;
☐
☐
2. The IHP data is stored in a secure provincial database known as, the Healthy Child Development -Integrated Services for
Children Information System (HCD-ISCIS);
☐
☐
3. The IHP will also share information with Healthy Child Development programs (Healthy Babies Healthy Children, Preschool
Speech and Language, Blind Low Vision) and other Health Care providers.
☐
☐
DPOAE
Lt
Pass
Refer
Did not test
No Result
Rt
Pass
Refer
Did not test
No Result
Tester
____________________________
Date 2 0 1 __ /__ __ /__ __
Hospital ________________________
(please print – Last name, First name)
y y y y
m m
d d
AABR
Lt
Pass
Refer
Did not test
No Result
Rt
Pass
Refer
Did not test
No Result
Tester
____________________________
Date 2 0 1 __ /__ __ /__ __
Hospital _________________________
(please print – Last name, First name)
y y y y
m m
d d
COMMENTS:
Early Discharge
Transferred out
Deceased
Other: _______________________________
10 rue Elm St., Suite/bureau 402, Sudbury Ontario P3C 5N3 Tel (705) 522-6655 Fax (705) 522-1215
RHC 616 March 2014
Page 1 of 1
Effective Date: March 12, 2014
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