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 No When and where was this test done before? Share result also(Required)Does your child has any speech or language concerns?(Required) Yes No 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 No Is there any history of hearing loss in your family?(Required) Yes No CAPTCHA Name of Child(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Referred By(Required)Please SelectENTPediatricianSelfOther medical professionalBirth HistoryTerm 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 No 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)Standing - (Months or Years)(Required)Did child had any viral infections/serious illness/Birth deformity/Seizure? If yes, explain the problem.(Required) Yes No Explain the Problem.(Required)Does any of your family members or close relative have a Speech or hearing problem?(Required) Yes No Was hearing screening/evaluation done in the past?(Required) Yes No Any previous reports of Audiological evaluation? Please bring during clinic visit.(Required) Yes No Did the child ever had any ear discharge/ ear pain?(Required) Yes No Did the child ever complained about a ringing sound from the ear?(Required) Yes No Is the child a mouth breather or snores at sleep?(Required) Yes No Does the child have sinus problem or frequent cold?(Required) Yes No Communication ModeHow 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 AspectsWhat is the type of family the child is in?(Required) Joint Family Nuclear Family Are both the parents working?(Required) Yes No 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 ComplaintWhat is the reason for consultation?(Required) Delay in Speech Hearing Loss Attention Problem Unclear Speech Overall Communication Problem Describe the Problem(Required)
