Fillable Audiology Child Case History

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Audiology Child Case History

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CALIFORNIA STATE UNIVERSITY, FRESNO
Speech, Language, and Hearing Clinic
Audiology Case History – Child
Name___________________________________ DOB______________Gender________
Address_____________________________________________Phone________________
Parent’s Name_________________________________
Referral Source____________________________Physician________________________
Do you suspect your child has hearing difficulties?____________ Which ear?___________
Explain:______________________________________________________________________
_____________________________________________________________________________
What do you think caused the problem? ____________________________________________
AUDIOLOGICAL HISTORY
Has your child ever had a hearing evaluation?________Where and when?____________
Has your child ever tried hearing aids?______ What type?_________Which ear(s)?_____
Is your child currently wearing hearing aids?________
Daily, how many hours does your child wear the hearing aids? __________
Has your child accepted the hearing aids?______________
MEDICAL HISTORY
Has your child experienced ear infections? ________ Which ear(s)?____________
How frequently?_____________ Type of treatment?_____________________________
Has your child ever been hit over the head and knocked out?________ Which side?_____
What happened?__________________________________________________________
Did you notice any hearing difficulties after the following illnesses: chicken pox ______
Mumps______measles_____scarlet fever______meningitis_____ototoxic drugs_______
FAMILY HISTORY
Are there other family members with a history of ear infections?_______ Who?________
Are there other family members with a hearing loss?_______ Who?_________________
When was the onset of their hearing loss?_______________________
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Audiology Child Case History

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Completed 22 May 2020

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