The Center for Hearing and Speech

The Center for Hearing and Speech

SECTION 1: PERSONAL INFORMATION

Child’s Name: ______Age: ______

DOB: ______/______/______Gender: c Male c Female

Ethnicity: c African American c Asian-Pacific c Caucasian c Hispanic c Other

Insurance: c Medicaid c Private Ins. c CSHCN c No insurance

Address: ______

Street Apt. #

______

City State Zip Code County

Home phone number: (____) ______-______Cell phone number: (____) ______-______

E-mail Address: ______

Father’s Name: ______Mother’s Name: ______

Father’s Employment: ______Mother’s Employment: ______

Father’s Work Number: (____) ______-______Mother’s Work Number: (____) _____-______

Do both parents live in the home? c YES c NO Is your child adopted/fostered? c YES c NO

Name of Pediatrician/ Physician: ______

Physician Phone: (______) ______-______Physician Fax: (______) ______-______

Address: ______

Street City State Zip Code

Emergency Contact: ______Phone Number: (_____) ______-______

Name/Relation

SECTION 2: REFERRAL INFORMATION

Who referred you for today’s services? ______

What is their phone number? (______) ______-______

SECTION 3: PRENATAL HISTORY

Where was your child born? Hospital: ______Other: ______

Was this a normal pregnancy/delivery? c YES c NO

If no, check all that apply: c Anoxia c Cesarean Section (c emergency c scheduled)

c Pulmonary Hypertension c Premature Delivery c Other: ______

SECTION 4: FAMILY, HEARING, COMMUNICATION, AND MEDICAL HISTORY

Family= parents, brothers, sisters, aunts, uncles, cousins and grandparents

Does anyone in the child’s family have hearing loss? c YES c NO If yes, whom? ______

Do they wear hearing aids? c YES c NO

Did your baby pass his/her newborn hearing screening after they were born?

Right ear: c YES c NO c I DON’T KNOW

Left ear: c YES c NO c I DON’T KNOW

Are you concerned about your child’s hearing? c YES c NO

If yes, why? ______

Has your child’s hearing ever been tested? c YES c NO

Where? ______Date of most recent test: _____/_____/______

Does your child have a known hearing loss? c YES c NO

If yes, which ear? c Right c Left c BOTH

What type? Right: Conductive/Sensorineural/Mixed Left: Conductive/Sensorineural/Mixed

What degree? Right: ______Left: ______

When was your child diagnosed? _____/_____/______Cause of loss: ______

How does your child communicate? c Spoken Words c Sign Language c Sign Lang. & Voice c No Language

Has your child had any of the following medical problems/childhood diseases? Check all that apply.

c Allergies c Balance, Gait, Coordination c Cerebral Palsy c Cleft Palate c CMV

c Craniofacial Abnormalities c Extended NICU stay c Extended Ventilation Use c Rubella

c Genetic Disorder or Syndrome (Name of Disorder/Syndrome: ______)

c Head Trauma c High Fevers c Jaundice c Meningitis c Mumps

c Low birth weight (less than 5 pounds) c Ototoxic Medications

c Seizures c Vision problems c Other: ______

Ear problems = ear infections or aches, drainage, hole in eardrum, fluid in ears, etc.

Has your child ever had any ear problems? c YES c NO

If yes, describe: ______

Has your child had any ear problems in the past 6 months? c YES c NO

Did your child have ear problems before the age of 1? c YES c NO

How many ear problems has your child had in his/her life? c 0-2 c 3-5 c 6-10 c 11 or more

Has your child ever had tubes placed in his/her eardrums? c YES c NO

If yes, when? _____/_____/______Dr. Name:______

SECTION 5: INTERVENTION SERVICES

Does your child receive Early Childhood Intervention (ECI) services in your house? c YES c NO

If yes, check all that apply.c Occupational Therapy c Physical Therapy c Speech Language Pathology

Therapists’ Names: ______

Is your child receiving Auditory Impaired (AI) Services in your house? c YES c NO

Therapist’s Name: ______

Is your child receiving speech therapy in a clinic? c YES c NO

If yes, Clinic Name? ______Therapist’s Name: ______

Is your child pulled for speech therapy in school? c YES c NO If yes, which type? c Individual or c Group

Therapist’s Name: ______

SECTION 6: EDUCATION PLACEMENT

Does your child attend school? c YES c NO Name of School: ______

Grade: ______School District (attending or zoned): ______

What type of classroom is your child in? c Regular Classroom c Special Education

c Hearing Impaired Classroom: c Spoken Language c Total Communication c American Sign Language

Teacher’s Name: ______

School Phone Number: (______) ______-______

SECTION 7: HEARING AID INFORMATION

Does your child currently use hearing aids? c YES c NO If yes, which ear? c Right c Left c BOTH

When was your child fit with a hearing aid? Right: _____/_____/______Left: _____/_____/______

Does your child wear his/her hearing aid(s) consistently at School?c YES c NO Home? c YES c NO

How much benefit do you observe when your child wears his/hear hearing aid(s)?

c No Benefit c Some Benefit c A Lot of Benefit

Does your child use an assistive listening device (i.e. FM System)? c YES c NO

If yes, which ear? c Right c Left c BOTH

SECTION 8: COCHLEAR IMPLANT INFORMATION

Does your child use a cochlear implant (CI)? c YES c NO

If yes, which ear? c Right c Left c BOTH

If yes, when was your child implanted? Surgery Date: Right: _____/_____/______Left: _____/_____/______

What month and year was your child’s CI activated: Right:______Left:______

What device/devices does your child wear? c Advanced Bionics c Cochlear c Med-El

CI Surgeon: ______CI Audiologist: ______

Last mapping session: _____/_____/______CI Center: ______

pg. 3