Child Case History Form-Audiology-Medical History Form
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2THE GEORGE WASHINGTON UNIVERSITY SPEECH AND HEARING CENTER
Child Case History Form – Audiology
Date _______________________________________
Name ___________________________________ Sex _________ Date of Birth ____________________ Age _________
Parent(s) or Guardian(s) ______________________________________________________________________________
Address ______________________________________________ Phone (home) ________________________________
City __________________________ State/Zip ______________ Phone (work) ________________________________
School __________________________________ Physician ________________________________________________
Referred by ___________________________________________
Statement of Release
I, ______________________________ , hereby request and/or grant permission to the above Clinic to send a report of
(signature)
diagnostic findings, evaluation and therapy progress of this case to the following:
Title or Name ________________________________________
Address ________________________________________
Title or Name ________________________________________
Address ________________________________________
Statement of Problem
Chief complaint/Reason for referral _____________________________________________________________________
When did you first notice this problem? _________________________________________________________________
Has child been elsewhere in regard to this problem? _________ If so, when, where and what was suggested? _________
_________________________________________________________________________________________________
What medical audiologic exams or treatment have you had for this problem? ____________________________________
_________________________________________________________________________________________________
What do you think caused the problem? _________________________________________________________________
What difficulties have been experienced related to hearing? __________________________________________________
_________________________________________________________________________________________________
If you think a hearing loss is present, list the sounds that your child seems to hear well or consistently ________________
_________________________________________________________________________________________________
ENT History
Has your child ever had ear infections: ______________ How frequently? _____________________________________
When was the last infection? ______________________ How was it treated? ___________________________________
Has your child had draining ears? __________________ Does hearing seem poorer when child has a cold? ____________
Are colds frequent? _____________________________ Does your child have allergies? __________________________
Does child take medication for allergies? ____________ Does wax accumulate rapidly in ears? _____________________
Has he/she ever had ear surgery of any kind? _________ Describe ____________________________________________
When, where and by whom? __________________________________________________________________________
Does child still have tonsils and adenoids? ___________ When were they removed? ______________________________
Do they cause any difficulty? ___________ Is child a mouth breather? ____________ Does child snore? ____________
Has child ever worn a hearing aid? _________________ (age first worn and type of aid) __________________________
_________________________________________________________________________________________________
Was the aid beneficial? __________________________ Ear(s) ______________________________________________
General Medical History
What illnesses has child had (age)? _____________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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