Auditory Processing Case History Form
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4Auditory Processing Evaluation - Page 1 of 4
STONY BROOK UNIVERSITY MEDICAL CENTER
AUDITORY PROCESSING CASE HISTORY FORM
You must bring a prescription from your child’s Doctor on day of your first
appointment or we will not be able to perform the test.
If you are being referred by a school district, you must consult with your MD and
request a prescription.
TODAY’S DATE: _________________________
CHILD’S NAME: ____________________________________
DOB: ___________________
ADDRESS:___________________________________________________________
CITY:_____________________________________ZIP:________________________
PHONE (H): ___________________ (W): ____________________ (C): ___________________
E-MAIL ____________________________ (
in the event we are unable to reach you by phone)
INSURANCE: _____________________________ REFERRAL NEEDED?
Y
N
Results will not be available on the day(s) of the evaluation as all results must be analyzed. A report
will be ready by 10-14 days after testing is complete. The report will explain findings and
recommendations for school and home. Parents may also contact the audiologist who completed the
evaluation if they have any questions about the results.
Referred by ________________________________________________
Person completing form □Parent/Guardian □ Other-Name/Relationship __________________
Results will be sent to names/locations listed below if address or faxes are provided
Name
Address or Fax
Phone
____________________________________________________________________________
____________________________________________________________________________
information
Disclosure of healthcare
will only be provided if authorized by the patient or legal
guardian except for known healthcare providers.
____________________________________________________________________________
Name
Relationship to patient
Address
phone
fax
____________________________________________________________________________
Name
Relationship to patient
Address
phone
fax
I authorize the Department to disclose healthcare information to names above. Valid for one year.
Signature of □ Patient □ Parent/Guardian _____________________________ Date __________
Printed Name of Parent/Guardian ________________________________________
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