Confidential Paediatric Hearing History

Patient details:

Name:

Address:

Email:

Medicare #:

DOB:

Postcode:

Tel:

Briefly describe your main concerns regarding your child’s hearing:

Tick the boxes relevant to your child’s hearing:

A family history of congenital hearing loss
Delayed Speech and Language Development
Previously diagnosed hearing loss
Has a history of ear surgery
A history of ear infections
Have concerns regarding auditory processing
Has problems hearing you
Diagnosed with ADHD or a Spectrum Disorder

Referred By:

Doctors Name:

Practice Address:

Practice Email:

Practice Name:

Postcode:

Practice Tel:

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