Illinois Department Of Public Health Newborn Hearing Screening Audioloortgy Follow Up Services Rep

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ILLINOIS DEPARTMENT OF PUBLIC HEALTH
NEWBORN HEARING SCREENING- AUDIOLOGY FOLLOW-UP SERVICES REPORT
CHILD’S NAME:
______________________
Med.ID: ________________
NAME BABY MAY ALSO BE KNOWN AS:
____________________________________________________________________________________________________________
_______________
DATE OF BIRTH:
SEX:
Male _______
Female _______
_________________________________________
BIRTH HOSPITAL:
MOTHER’S (GUARDIAN’S) NAME: ____________________________________________________________________________
(Last)
(First)
(MI)
ADDRESS: _________________________________________________________________________________________________
(Street)
(Apt. #)
____________________________________________________________________
(______)__________________________
(City)
(State)
(Zip)
(County)
(Phone)
DIAGNOSIS:
RIGHT
LEFT
Hearing Within Normal Limits
Sensorineural Hearing Loss
Conductive Hearing Loss
Mixed Hearing Loss
Undetermined Type Hearing Loss
DEGREE OF HEARING LOSS:
RIGHT
LEFT
Mild Hearing Loss
Moderate Hearing Loss
Severe Hearing Loss
Profound Hearing Loss
Sloping Hearing Loss: Describe per ear:
_________
________
DATE OF THIS EVALUATION: ________________________________________________________________________________
IS THERE A FAMILY HISTORY OF CONGENITAL HEARING LOSS? _______________________________________________
LIST ANY KNOWN RISK FACTORS FOR HEARING IMPAIRMENT: ________________________________________________

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