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Pediatric Case History Form

Name*
First Last
Today's Date*
MM
DD
YYYY
DOB*
MM
DD
YYYY
Gender*
- Male
- Female
Primary Language*
- English
- Spanish
- French
Current School*
Grade Level*
- Preschool
- Kindergarten
- 1st Grade
- 2nd Grade
- 3rd Grade
- 4th Grade
- 5th Grade
- 6th Grade
- 7th Grade
- 8th Grade
- 9th Grade
- 10th Grade
- 11th Grade
- 12th Grade
Grade Level*
Home Status*
- Lives with both parents
- Shared custody
- Grandparents
- Other
Does anyone in the home smoke?*
- Yes
- No
Amount Per Day*
Type*
- Cigarettes
- Cigars
- Pipe
Audiologic History
Do the child experience hearing loss?*
- Yes
- No
Which ear does the child experience hearing loss?*
- Right
- Left
- Both
Please describe the child's hearing loss*
- Gradual
- Fluctuating
- Sudden
When did you first notice the child's hearing loss?*
What do you think caused the hearing loss?*
Had the child ever had a hearing test?*
- Yes
- No
When did the child have the hearing test?*
Did the child pass their newborn hearing screening?*
- Yes
- No
Where did the child have their hearing test?*
Has the child ever worn a hearing aid?*
- Yes
- No
Where has the child worn a hearing aid?*
- Right
- Left
- Both
What type and style of hearing aid?*
Please describe the child's experience with the hearing aid*
Please check all medical conditions that apply:
- Developmental disorder/delay
- Dizziness/Unsteadiness
- Ear Deformity
- Ear Drainage
- Ear Pain
- Family history of hearing loss
- History of ear infections
- History of wax buildup
- History of noise exposure
- History of ear surgery
- Tinnitus/Ear noises
- Other
Explain developmental disorder/delay*
Dizziness/Unsteadiness is accompanied by:*
- Nausea
- Vomiting
- Ear noises
Ear Deformity*
- Right
- Left
- Both
Ear Drainage*
- Right
- Left
- Both
Ear Pain*
- Right
- Left
- Both
Who in your family history with a hearing loss?*
History of ear infections*
- Right
- Left
- Both
When were the ear infections?*
Describe history of noise exposure*
Ear surgery*
- Right
- Left
- Both
When was the ear surgery?*
Tinnitus/Ear noises*
- Right
- Left
- Both
Frequency of the Tinnitus/Ear noises*
Describe other medical history*
Medical History
Please list any other illnesses, injuries, hospitalizations, or surgeries and their date(s) of occurrence:
Occurrence Date
Allergies (food, plastics, medications, etc):
Has the child been immunized?*
- Yes
- No
For what disease?*
Have you experienced any of the following medical conditions?
- AIDS/HIV
- Appetite change
- Arthritis
- Blood disorders
- Cancer
- Chicken pox
- Diabetes
- Diphtheria
- Encephalitis
- Fatigue
- Genetic disorders
- Head injury
- Headaches
- Heart Problems
- High blood pressure
- High fevers
- Influenza
- Malaise
- Malaria
- Measles
- Meningitis
- Mumps
- Scarlet fever
- Stroke
- Tonsilitis
- Typhoid
- Vascular problems
- Other
Please mark all medical symptoms that apply:
- Allergic/immunologic (hives, asthma, itching, immune deficiency)
- Cardiovascular (chest pain, swelling, palpitations)
- Endocrine (frequent urination, hot flashes)
- Eye problems (blurred vision, pain)
- Gastrointestinal (nausea, vomiting, weight change, diarrhea, pain)
- Hemotologic/lymphatic (bleeding gums, bruising, swollen glands)
- Musculoskeletal (joint pain, swelling, recent trauma)
- Neurological (numbness, headaches, seizures, muscle weakness)
- Nose, Throat, or Mouth Problems (swallowing, nose bleeds, dental issues, pain)
- Psychiatric (depression, anxiety, compulsions)
- Respiratory (shortness of breath, coughing, wheezing)
I certify this information is true and correct to the best of my knowledge.*
- I will notify you of any changes in the above information. I authorize the release of any medical information necessary to provide treatment and bill my insurance.
Name*
Date*
Date Format: MM slash DD slash YYYY
Email*
Prove Your Humanity

Δ

(317) 620-1897

Pediatric Case History Form

Audiologic History

Medical History

Office Hours

Monday - Thursday 9:00 am - 5:00 pm
Friday 9:00 am - 12 Noon
Additional times are available by appointment.

Occurrence	Date

(317) 620-1897

Pediatric Case History Form

Audiologic History

Medical History

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Office Hours

Monday - Thursday 9:00 am - 5:00 pmFriday 9:00 am - 12 Noon Additional times are available by appointment.

Monday - Thursday 9:00 am - 5:00 pm
Friday 9:00 am - 12 Noon
Additional times are available by appointment.