History Form for Students with Hearing Impairment Student Information: Student's Name: ______________________ Date of Birth: ______________________ Gender: ______________________ Grade/Class: ___________________ School Name: ______________________ Contact Information (Parent/Guardian): _________________________________ Name: ___________________________ Phone Number: ___________________________ Email: _________________________________ Date of Assessment: _________________________ Hearing History: _________________________________________ Date of Onset of Hearing Loss: _____________________________________ Cause of Hearing Loss (if known): ______________________________________ Previous Audiological Evaluations (if any): ______________________________________ Date: ______________________________________ Results: ______________________________________ Hearing Devices: ______________________________________ Type of Hearing Device(s) (e.g., hearing aids, cochlear implants): ______________________________________ Date of Fitting: ______________________________________ Make/Model: ______________________________________ Current Functionality: ______________________________________ Communication and Language: ______________________________________ Primary Mode of Communication (e.g., sign language, speech, lip-reading): ______________________________________ Language(s) Spoken at Home: ______________________________________ Additional Communication Support Required (e.g., interpreter): ______________________________________ Educational History: ______________________________________ Educational Placement: ______________________________________ Mainstream Classroom: ______________________________________ Special Education Classroom: ______________________________________ Resource Room: ______________________________________ Other (Specify): ______________________________________ Individualized Education Plan (IEP) in place: ______________________________________ Specialized Services Received (e.g., speech therapy, sign language instruction): ______________________________________ Social and Emotional Development: Any Behavioral or Emotional Concerns: ______________________________________ Social Skills and Interactions with Peers: ______________________________________ Coping Strategies for Hearing Impairment: ______________________________________ Medical History: ______________________________________ Relevant Medical Conditions or Allergies: ______________________________________ Medications (if any): ______________________________________ History of Ear Infections or Surgeries: ______________________________________ Assistive Technology: ______________________________________ Use of Assistive Listening Devices (e.g., FM systems): ______________________________________ Other Assistive Technology Utilized: ______________________________________ Additional Comments/Notes: ______________________________________