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Pediatric Case History

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Hearing Center Inc
PEDIATRIC CASE HISTORY

Patient Name: Date:
FAMILY HISTORY
1.Does anyone in your family have a hearing loss? Yes No
If yes, what is their relationship to you ?
2.When was their hearing loss discovered? Child Adult
3.Does he/she wear hearing aids? Yes No
HEARING HISTORY
4.Were there any complications(illness,medications,etc.) during the pregnancy
of your child? Yes No
If yes, please explain
5.Were there any complications with the delivery? Yes No
If yes, please explain
6.Has the child had:
a) Ear infections? Yes No
b) Tonsillitis? Yes No
c) Prolonged Fever? Yes No
If yes to any of the above, was a doctor consulted? Yes No
Was any treatment completed? Yes No
If yes, please explain
7.Is the child aware of sound? Yes No
8.Does the child respond to his/her name? Yes No
9.Does the child have intelligible words? Yes No
If yes, approximately how many words?
How many sentences?
10.Does the child listen to music or TV too loudly? Yes No
11.Does the child socialize at school? Yes No
12.Is the child's school performance good? Yes No
13.Has the child's hearing ever been tested before? Yes No
If yes,when and where?
What were the results?
14.Do you think the child has diffcults hearing? Yes No
If yes, how long have you notice this?
Has anyone else notice this diffcults? Yes No
If yes, who and for how long?
Has the hearing seemed too decreased? Yes No
In what situations do you notice this decrease?
COMMENTS:

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