Pediatric Patients History Form for Hearing Test

+91-11-4608 5246
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Mon - Sat : 10:00 AM - 06:00 PM

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+91-11-4608 5245

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Pediatric Patients History Form

Child name(Required)

Date of birth(Required)

MM slash DD slash YYYY

Age(Required)

Please enter a number from 0 to 18.

Father's name(Required)

Mother's name(Required)

Referred by :(Required)

ENT

Pediatrician

Self

Any Other Medical / Prof

ENT name(Required)

Pediatrician(Required)

Self(Required)

Any other medical/prof name(Required)

Why do you feel the need for hearing test?(Required)

Has any hearing test been done before?(Required)

Yes

When and where was this test done before? Share result also(Required)

Does your child has any speech or language concerns?(Required)

Yes

Describe the concern's that you have regrading child's speech?(Required)

At what age your child start speaking?(Required)

1 Year

2 Year

3 Year

Any medical history that you want to share regrading your child at?(Required)

Birth

Later

Medical history that you want to share regrading your child at birth?(Required)

Medical history that you want to share regrading your child at later?(Required)

Any developmental delay_______ motor skills?(Required)

Any special services child is availing _____ speech occupation?(Required)

Does your child have a history of ear infection?(Required)

Yes

Is there any history of hearing loss in your family?(Required)

Yes

CAPTCHA

Name of Child(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Referred By(Required)

Birth History

Term of Child’s Birth(Required)

Full Term

Preterm

Mention gestational month of birth(Required)

Delivery type(Required)

Normal delivery

Caesarian

Forceps delivery

Vacuum delivery

Delivery Complications if any : -

Birth cry(Required)

Child Cried Immediately After Birth

Delayed Birth Cry

Weight of Child at Birth(Required)

Normal (within 2.5kg-3.5kg)

Low birth weight (<2.5kg)

Overweight (>3.5kg)

Admitted in NICU(Required)

Yes

Reason for Admitting(Required)

Describe at what age the following motor developments were attained by the child (mention in months or years).(Required)

Head Control

Sitting

Standing

Head Control - (Months or Years)(Required)

Standing - (Months or Years)(Required)

Did child had any viral infections/serious illness/Birth deformity/Seizure? If yes, explain the problem.(Required)

Yes

Explain the Problem.(Required)

Does any of your family members or close relative have a Speech or hearing problem?(Required)

Yes

Was hearing screening/evaluation done in the past?(Required)

Yes

Any previous reports of Audiological evaluation? Please bring during clinic visit.(Required)

Yes

Did the child ever had any ear discharge/ ear pain?(Required)

Yes

Did the child ever complained about a ringing sound from the ear?(Required)

Yes

Is the child a mouth breather or snores at sleep?(Required)

Yes

Does the child have sinus problem or frequent cold?(Required)

Yes

Communication Mode

How does the child convey his/her needs?(Required)

Uses simple words

Uses pointing and actions

Uses sentences

Uses vocalizations

Crying

How many words the child uses meaningfully? (Approximate count of words child uses including family members, name of objects etc.)(Required)

Does the child uses sentences for communication? What is the maximum number of words used in a sentence?(Required)

Social Aspects

What is the type of family the child is in?(Required)

Joint Family

Nuclear Family

Are both the parents working?(Required)

Yes

Average time of screen usage (TV or mobile phone) by the child per day?(Required)

What school setup the child is attending?(Required)

Mainstream School/Normal School

Special School

Playschool

Any complaint from school reported?(Required)

Chief Complaint

What is the reason for consultation?(Required)

Delay in Speech

Hearing Loss

Attention Problem

Unclear Speech

Overall Communication Problem

Describe the Problem(Required)

Products

Cochlear Implant System
Hearing Aids
BAHA
Middle Ear Implant
Auditory Brainstem Implant

Services

Audiology
Adult
Speech And Language Therapy

SpHear Speech & Hearing Clinic

DELHI

G-32, LGF, Lajpat Nagar-III,
New Delhi – 110 024
Tel: +91-11-4608 5245
+91-11-4608 5246

PATNA

Rajender Nagar, Road Number-8,
Rajendra Nagar, Patna – 800 016
Tel: +91-612-267 2906,
Mob: +91-98350 22492

NOIDA

E 152, Basement, Sector-20,
Noida – 201 301
Tel: +91-120-422 5246
Tel: +91-120-422 5247

About SpHear Clinic

A clinic where we understand that addressing a patient’s unique listening needs is the key to helping him/her.
SpHear Clinic offers personalized hearing, speech and communication services, in addition to the latest hearing device technology. We are dedicated to …. Read More

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