Infant Hearing Health History
Infant’s Name:
Home Address:
____________________________ Today’s Date:
____________________________
____________________________ Parent(s):
____________________________
____________________________ Phone Number: ____________________________
Date of Birth:
______________ Age (months): _____________ Gender: _____________________
Pediatrician:
____________________________ Pediatric Group: ____________________________
Sibling(s) (names & ages): _________________________________________________________________
Information Provided By: _____________________ Relationship to Infant:
_____________________
Referred By:
____________________________ Send Report To: ____________________________
Background Information
Do you have concerns regarding your baby’s hearing?

yes

no
If so, please describe:
_________________________________________________________________
Did you baby receive the Universal Newborn Hearing Screening?

yes

no
If so, what were the results?

passed 
failed
Is there a family history of hearing loss? (parents, siblings, etc.?)

yes

no
Has you baby received any other evaluations since birth?

yes

no
If yes, please list:
_________________________________________________________________
Has your baby seen any of the following specialists?

Otolaryngologist (ENT)

Genetic Counselor

Neurologist

Other: ______________
Pregnancy History
Length of pregnancy (full term, premature, late):
___________________________________________
Medications/Drugs used during pregnancy:
___________________________________________
Frequency of alcohol use during pregnancy:
___________________________________________
Illnesses/Infections during pregnancy:
___________________________________________
Did you contract, or were you exposed to any of the following during your pregnancy?

Cytomegalovirus (CMV)

High fever

Industrial solvents (toluene, styrene)

Rubella

Bacterial meningitis

Sepsis

Toxoplasmosis (exposure to cat litter)

Syphilis

Chemotherapeutic drugs (cisplatin)

Loop diuretics

Herpes simplex virus

Carbon monoxide (CO)

Aminoglycoside antibiotics

Gentamycin

Streptomycin

Tobramycin

Rhodostretomycin

Neomycin

Teratogens

Tobacco

Radiation

Alcohol

Lead

Intravenous (IV)/Illicit Drugs
Birth History
Birth weight:
____________________________ Weeks premature/late: _____________________
Were there any delivery complications?

yes

no
If yes, please explain:
_________________________________________________________________
Hasa your baby ever received any of the following since birth?

Placement on an Extra Corporeal Membrane Oxygenation (ECMO) machine

A stay in the Neonatal Intensive Care Unit (NICU) longer than five days

Placement on an assisted ventilation machine

Light treatment for hyperbilirubinemia (jaundice)

Loop diuretics (for poor kidney function)

Gentamycin, tobramycin, or other aminoglocoside antibiotics for infection(s)
Medical History






High fever
Seizure disorder/convulsions
Past/present medications:
Hospitalizations:
Surgeries:
Medical conditions:
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Developmental & Social History
Does your baby startle/respond to loud sounds (eye blink, cry, head turn)?
 yes
 no
Is there a history of hearing loss with any parents, siblings, or cousins?
 yes
 no
Describe any diagnosed developmental delays your baby may have (autism, mental retardation, etc.):
______________________________________________________________________________________
Describe any behavioral problems your baby may have:
______________________________________________________________________________________
Ear History
Has your baby ever had an ear infection?
If yes, how many?
When was the most recent ear infection?
Has your baby ever been treated with antibiotics for an ear infection?
Is your baby currently on antibiotics for treatment of an ear infection?
Has your baby ever received pressure equalization (PE) tubes?
Does your baby have frequent colds or congestion?

yes

no
____________________________
____________________________

yes

no

yes

no

yes

no

yes

no
Additional Information
______________________________________________________________________________________
______________________________________________________________________________________
___________________________________
Signature of Person Providing Information
Revised 1/3/2011