Pe
SHA
803-469-7770
Fax: 803-469-7701
Sumter Hearing Associates Quality. Education. Commitment.
email:
[email protected] www.sumterhearing.com 1116 F Alice Drive - Sumter, SC 29150 23 South Mill St. – Manning, SC 29102
Pediatric Case History Name: __________________________________ DOB: _________________ Date: ______________ Referred: ________________________________ Accompanied by: ____________________________ 1. What reason was this hearing test arranged: _____________________________________________ 2. Ever had a hearing test? _____________________________________________________________ 3. Trouble hearing? __________________________________________________________________ 4. Seem to hear on some days than others? ________________________________________________ 5. Tinnitus? ________________________________________________________________________ 6. Dizziness? _______________________________________________________________________ 7. Does anyone in the family have a problem with hearing? __________________________________ 8. Exposure to hazardous noise? ________________________________________________________ 9. Were there any complications during birth? _____________________________________________ 10. General health: Good ___ Average ___ Poor ___ 11. Taking medications now? ___________________________________________________________ 12. Ever been hospitalized? ____________________________________________________________ 13. Ear surgery? _____________________________________________________________________ 14. Other illnesses? ___________________________________________________________________ 15. Do you have any concerns about your child’s physical or mental development or speech and language? __________________________________________________________________________________ 16. Repeated any grades? ________________________________________________________________ 17. Give school and grade - any special services? _____________________________________________ 18. Do you believe your child has any learning problems? ______________________________________ 19. What questions would you like to have answered as a result of today’s hearing test? _____________ _________________________________________________________________________________ 20. Whom would you like to receive reports? ________________________________________________ OFFICE USE SF VRA SAT
1000Hz
500Hz
2000Hz
4000Hz
updated 9/2018
