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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: ______________________________________
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