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Ida Institute
https://idainstitute.com/fileadmin/user_upload/documents/Case%20History%20Form.docx#:~:text=History%201.%20Have%20you%20had%20your%20hearing%20tested,from%20the%20ear%20within%20the%20past%2090%20days%3F
PEDIATRIC CASE HISTORY – AUDIOLOGY - Dr. Malis
https://myfamilyent.com/wp-content/uploads/Malis_PediatricAudiologicalCaseHistory.pdf
HEARING ABILITY 1. Does your child have a hearing impairment? Yes No Not sure 2. Does he/she use hearing aids or a cochlear implant? Yes No If so, what type? _____ (Please bring to appointment) 3. Does the child: Consistently respond to sounds? Yes No Turn toward loud sounds? Yes No Look when his/her name is called? Yes No
Pediatric Audiology Case History - Wichita State …
https://www.wichita.edu/academics/health_professions/slhclinic/documents/Peds_Aud_case_history_form.pdf
The following questions are designed to help us evaluate your child’s auditory system. Please answer them as accurately and completely as possible. If a question does not apply please write NA. 1. What is the primary reason for this appointment? _____ _____ 2. Do you feel your child’s hearing is stable or does it fluctuate?
Audiologic Case History for Children
https://audiology.okstate.edu/images/NEW_Case_History_PEDIATRIC_Audiology.pdf
Audiologic Case History for Children. Patient Name: _____ Birthdate: _____ Parent / Guardian Name: _____ Referred by: _____ Primary concern: _ _____ Do you think your child has a hearing loss? Yes No . Which ear? Right Left Both . Did your child pass a …
PEDIATRIC CASE HISTORY QUESTIONNAIRE …
https://www.etsu.edu/crhs/aslp/center/audiology-services/documents/pediatric-case-history.pdf
PEDIATRIC CASE HISTORY QUESTIONNAIRE . ... Do you think your child has difficulty hearing? ... Does this child have a family history of hearing loss? YES or NO If YES, please describe_____ Has your child received any hearing tests in the past? YES or NO If YES, when/where? ...
PEDIATRIC CASE HISTORY - Rem Audiology, Audiologist in ...
https://www.remaudiology.com/wp-content/uploads/2017/08/PedCaseHistory.pdf
HEARING HISTORY: YES NO Do you have any concerns about your child’s hearing? If yes, briefly explain:_____ Does anyone in your family have hearing loss (immediate and extended family) that began before the age of 30? If yes, please explain:_____
PEDIATRIC CASE HISTORY FORM FOR AUDIOLOGY …
https://www.usf.edu/cbcs/csd/documents/audiology-case-history-pediatric.pdf
Hearing Clinic (813) 974-8804 (813) 974-0822 - FAX Center for Speech, Language, and Hearing • 4202 E. Fowler Ave, PCD 1017 • Tampa, FL 33620 rev. 10/09/08 . PEDIATRIC CASE HISTORY FORM FOR AUDIOLOGY . Date form completed: _____ File # _____ (office staff) IDENTIFYING AND BACKGROUND INFORMATION
Hearing Case History - American Speech-Language …
https://www.asha.org/public/hearing/Hearing-Case-History/
The audiologist may ask any of the following questions: What brought you here today? Have you noticed problems with your hearing? What problems have you had? How long have you had them? Do you have problems hearing in one ear or both ears? Did your hearing loss happen all of a sudden? Or, has it gotten worse over time? Do you have ringing in your ears?
Speech-Language-Hearing Case History Questionnaire
http://www.positivestepstherapy.com/wp-content/uploads/2015/02/Speech-Language-Questionnaire.pdf
Speech-Language-Hearing Case History Questionnaire 4 Oral Motor/Feeding Please tell the approximate age that your child achieved the following feeding milestones: _____ Drank from a sippy cup _____Consumed mashable table foods _____Drank from an open cup _____Consumed a variety of food textures _____Consumed solids
CHILD CASE HISTORY FORM AUDIOLOGY - University of Arizona
https://slhs.arizona.edu/sites/default/files/Audiology%20Child%20Case%20History%20form.pdf
II. GENERAL HISTORY: What is the child's problem? When did you first notice it? What do you think caused it? Has anyone in your family ever had a speech, language or hearing problem during their childhood? III. HEALTH HISTORY: Were there any significant problems during the pregnancy or the delivery or following the birth with the child?
The Pediatric Case History - Ento Key
https://entokey.com/the-pediatric-case-history/
As with any other patient coming in to have their eyes examined, the single most important question in the pediatric case history, and the first one to ask, is what is the chief complaint? What is (are) the problem(s) that you have noticed and what are your (the parents[s]) concerns? That is, “what is the reason(s) you are here?”
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