Download Pediatric Case History Form

Audiology Case History Form (Pediatric)
University of Hawai`i Speech & Hearing Clinic
677 Ala Moana Blvd., Suite 625, Honolulu, HI 96813
Phone: (808) 692-1580; Fax: (808) 566-6292
Patient: ______________________________________________ Today’s Date: _______________________
Date of Birth: ____________ Age: _____ Sex: Male / Female Referred by ______________________
Name of Person Giving Information: ________________________________ Relationship: _______________
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With whom does your child live? __________________________________________________________
What is the primary reason for this appointment?
_____________________________________________________________________________________
_____________________________________________________________________________________
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Has your child received medical attention regarding your concerns? □ No □ Yes
If yes: Date _______________________ Doctor’s Name: ________________________
Findings: _____________________________________________________________________________
When was the problem first suspected? _____________________________________________________
Please check all that apply to your child’s symptoms.
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Hearing loss
Ear drainage
Ear pain/discomfort
Fullness/pressure in the ear
Dizziness or vertigo
Destructed by background noise
Oral and written expression problems
Remembering what they hear
Learning to read
Tinnitus (ringing, buzzing in the ear)
□ Right □ Left □ Equal
□ No □ Yes □ Did not have screening
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Does your child seem to have a better hearing ear?
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Did your child pass a newborn hearing screening?
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Has your child’s hearing been tested before by audiologists?
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Problems following directions
No
Yes, When was the last hearing test?__________________ Where?________________
Results: _____________________________________________________________________
Has your child ever worn hearing aids?
□ No
□ Yes, ear __________
Were you satisfied? □ No
If yes, where and when did you purchase them?
□ Yes
_____________________________________________________________________________________
_____________________________________________________________________________________
Hearing Aid Make/Model: _______________________________________________________________
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Do you feel your child needs hearing aids?
□ No
□ Yes
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5/8/13
Medical History
 Condition during pregnancy:
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a) Illness ___________________________________________________
b) p.h. Factor ________________________________________________
c) Other ____________________________________________________
Condition during or following birth:
a) Length of pregnancy _________________________
b) Birth weight ________________________________
c) Complications (breech, Caesarian) _______________________________________________
Your child’s history of illness (please indicate age)
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Meningitis
Mumps
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epilepsy
High fevers
Convulsions
Allergies
Accidents or
surgery
□ Ear infections
Scarlet fever
Tonsillitis
Were any of the following present in your child’s life (please check all that apply)?
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Measles
Head trauma
Assisted ventilation
Neonatal intensive care for > 5 days
Hyperbilirubinemia (jaundice)
Anoxia (oxygen deprivation)
Ototoxic medications (e.g. gentamycin,
aminoglycoside, loop diuretics,
chemotherapy)
Infections at birth or in utero (e.g.
CMV, herpes, rubella, syphilis,
taxoplasmosis)
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Craniofacial anomalies (cleft lip or
palate, anomalies of the ear, anomalies
of the temporal bone)
Neurodegenerative disorders
Rh factor incompatibility
Postnatal infections associated with hearing
loss (e.g. herpes, meningitis)
Premature birth/birth weight less than 3.3 lbs.
Low Apgar score
Vision problems
Noise exposure
Nausea
Syndromes associated with hearing loss (e.g.
neurofibromatosis, Usher syndrome,
Waardenburg syndrome, CHARGE, Down
syndrome)
Does your child have any family members with hearing loss or other ear-related issues? □ No □ Yes
If so, please describe. __________________________________________________________________
Speech/Language/Gross Motor Development
 Developmental Milestones: At what age did your child:
Sit alone __________________
Walk _________________ Toilet trained __________________
 Speech and Language Development: At what age did your child
Babble __________
Use words __________
Use phrases __________ Use sentences _________
 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.)? ______________________________________________________
_____________________________________________________________________________________
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Does your child watch your face for communication clues?
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□ No
□ Yes
5/8/13
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Does your child appear to respond to: □ His/her name
□ Soft noise □ Loud noise □ Vibrations
□ Verbal instructions □ Verbal instructions with gestures
□ Gestures alone
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How do you communicate with your child? __________________________________________________
How does your child make his/her needs known to you? _______________________________________
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Has your child had speech and/or hearing therapy?
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Does your child currently receive support services (including speech-language therapy, occupational
□ No
□ Yes, where_______________________
therapy, physical therapy, special education)? □ No □ Yes
If so, please indicate which services: _______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Emotional Development
 How would you describe your child’s personality (calm, nervous, shy, happy, tense, etc.)?
_____________________________________________________________________________________
 Is your child easily managed in the home? __________________________________________________
 Would you describe your child as unusually active or distractible? _______________________________
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Does your child: □ Eat well
□ Sleep well □ Have nightmares □ Have fears
Does your child play with other children? □ No □ Yes
Do you feel his/her general behavior is similar to other children in his/her age? □ No
□ Yes
Scholastic Development
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Is your child in school? □ No
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How would you describe your child’s academic performance/progress?
_____________________________________________________________________________________
In what area is your child having difficulty? _________________________________________________
Where is your child seated in the classroom? _________________________________________________
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□ Yes, Grade _____________
Other
 How did you find out about our clinic?
□ Internet □ Friend □ Physician □ Insurance company □ Other _________________________
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Please provide any other information about your child’s general or hearing health that you feel may be
helpful to today’s appointment.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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5/9/13
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Please list current medications that your child is taking to the best of your knowledge and ability. The
medications include all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional
supplements.
Name of Medication
Dosage
(mg)
Frequency
(e.g. once a day,
twice a day etc.)
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Route of Administration
(e.g.oral, topical,
inhalation, injection etc.)
Conditions that Your
Child is Taking
Medications for
5/9/13