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Pediatric Audiology Intake Form

Please complete this Audiology intake form prior to your appointment. This will make your check-in process faster.

Patient Name

1. Any history of ear infections? YES/NO

2. Any history of ear surgery? YES/NO

3. Are there any parental or teacher concerns regarding your child’s hearing? YES/NO

4. Are there any previous hearing test/screenings (excluding newborn hearing screening)? YES/NO

5. Did your child pass his/her newborn hearing screening? YES/NO

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