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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: ___________________________________________ Page 1 of 3 Rev. 8/7/13 □ 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, Page 2 of 3 Rev. 8/7/13 □ 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? ________________________________ Page 3 of 3 Rev. 8/7/13