Download Supplemental Pediatric Hearing Case History Form

UNIVERSITY OF HAWAI'I SPEECH AND HEARING CLINIC
CHILD CASE HISTORY FORM
HEARING PROBLEMS
Please answer the following questions as best you can. If you cannot answer some of the questions, leave
them blank. Your answers will help in understanding your child’s problem and save time during the
conference. (An EO/AA Institution)
RETURN TO: University of Hawai'i Speech and Hearing Clinic
677 Ala Moana Blvd., Suite #625
Honolulu, Hawai'i 96813.
A. Hearing
Date: _____________________________
Please check all that apply to your child’s current symptoms.
□
Hearing loss, which ear? _____________
□
Problems following directions
□
Ear drainage, which ear? _____________
□
Distracted by background noise
□
Ear pain/discomfort, which ear? _______
□
Oral and written expression problems
□
Fullness/pressure, which ear? _________
□
Difficulty remembering what he/she hears
□
Dizziness or vertigo
□
Difficulty learning to read
□
Tinnitus (ringing, noise), which ear?____
□
Sensitivity to loud sounds
□
Fluctuating hearing loss, which ear?____
□
Other _____________________________
Does your child seem to have a better hearing ear?
□ Right □ Left □ Equal
Did your child pass a newborn hearing screening?
□ No
□ Yes □ No screening done
When did your child’s hearing problem(s) first develop? ______________________________
What is known or suspected cause of your child’s hearing difficulty? ______________________
Has your child’s hearing been tested before by audiologists?
□
No
□
Yes, When was the last hearing test?__________________ Where?___________________
Results:______________________________________________________________
Has your child ever worn any of the following devices? □No
□Yes, □Right/□Left/□Both Ears
□ Hearing aid
Make/Model:___________________________________________
□ Cochlear implant
Make/Model: ___________________________________________
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□ BAHA
Make/Model: ___________________________________________
□ FM system
Make/Model: __________________________________________
□ Other _____________
Make/Model: ___________________________________________
If yes, where and when did you obtain them? Were you satisfied?
□ No
□ Yes
Where? ____________________________________________________________________
When? ____________________________________________________________________
If no, do you feel your child needs hearing aids?
□ No
□ Yes
B. Medical History
Your child’s history of illness (please indicate age)
□
Measles ____________
□
Epilepsy____________
□
Allergies____________
□
Meningitis___________
□
High fevers__________
□
Accidents/ surgery______
□
Mumps____________
□
Convulsions____________ □ Ear infections_________
□
Scarlet fever____________
□
Tonsillitis___________
□
Other ____________________________________________________________________
□Acute / □Chronic
Were any of the following present in your child’s life (please check all that apply)?
□
Head trauma
□
□
Assisted ventilation
□
Neonatal intensive care for > 5 days
□
Hyperbilirubinemia (jaundice)
□
Anoxia (oxygen deprivation)
□
Ototoxic medications (e.g. gentamycin,
anomalies of the ear, anomalies of the
temporal bone)
□
□
Rh factor incompatibility
□
Postnatal infections associated with
hearing loss (e.g. herpes, meningitis)
□
Premature birth/birth weight < 3.3 lbs.
chemotherapy)
□
Low Apgar score
Infections at birth or in utero (e.g. CMV,
□
Vision problems
herpes, rubella, syphilis, taxoplasmosis)
□
Noise exposure
Neurodegenerative disorders
□
Nausea
aminoglycoside, loop diuretics,
□
Craniofacial anomalies (cleft lip or palate,
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□
Syndromes associated with hearing loss (e.g. neurofibromatosis, Usher syndrome,
Waardenburg syndrome, CHARGE, Down syndrome)
Has your child ever had surgery on/around his/her ears?
□ No
□ Yes, please describe.__________________________________________________
Does your child have any family members with hearing loss or other ear-related issues?
□ No
□ Yes, please describe.__________________________________________________
Does your child have any history of noise exposure (e.g. listening loud music)?
□ No
□ Yes, please describe.__________________________________________________
C. Communication
Are there any words that your child appears to understand, but cannot say (e.g. bye-bye, baby, no,
cookie, bath, follow simple instructions, etc.)?
______________________________________________________________________________
______________________________________________________________________________
Does your child watch your face for communication clues?
□ No
□ Yes
Does your child appear to respond to:
□ His/her name □ Soft noise □ Loud noise □ Vibrations □ Verbal instructions
□ Verbal instructions with gestures □ Gestures alone
How do you communicate with your child?___________________________________________
How does your child make his/her needs known to you? ________________________________
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