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Case history form
https://www.captel.com/2014/02/first-audiologist-visit-case-history-form/#:~:text=Case%20history%20form%201%20General%20hearing%20questions.%20How,you%20often%20speak%20too%20loudly%20in%20a%20conversation%3F
Hearing Case History - ASHA
https://www.asha.org/public/hearing/Hearing-Case-History/
The audiologist may ask any of the following questions: What brought you here today? Have you noticed problems with your hearing? What problems have you had? How long have you had them? Do you have problems hearing in one ear or both ears? Did your hearing loss happen all of a sudden? Or, has it gotten worse over time? Do you have ringing in your ears?
Your first audiologist visit: The case history form
https://www.captel.com/2014/02/first-audiologist-visit-case-history-form/
Case history form General hearing questions. How long have you noticed your hearing loss? Was it sudden or gradual onset? Have you been... Medical. Have you had earaches or pain in the last 90 days? Do you have ringing, buzzing, whooshing or roaring sounds in... Other. The case history will also ...
PEDIATRIC CASE HISTORY – AUDIOLOGY
https://myfamilyent.com/wp-content/uploads/Malis_PediatricAudiologicalCaseHistory.pdf
HEARING ABILITY 1. Does your child have a hearing impairment? Yes No Not sure 2. Does he/she use hearing aids or a cochlear implant? Yes No If so, what type? _____ (Please bring to appointment) 3. Does the child: Consistently respond to sounds? Yes No Turn toward loud sounds? Yes No Look when his/her name is called? Yes No
Case History Form for Adults – Audiology
https://www.usf.edu/cbcs/csd/documents/audiology-case-history-adult.pdf
Hearing Clinic (813) 974-8804 (813) 974-0822 - FAX Center for Speech, Language, and Hearing • 4202 E. Fowler Ave, PCD 1017 • Tampa, FL 33620 rev. 06/29/11 Case History Form for Adults – Audiology Please describe in your own words, your hearing difficulty: _____
Speech-Language-Hearing Case History Questionnaire
http://www.positivestepstherapy.com/wp-content/uploads/2015/02/Speech-Language-Questionnaire.pdf
Speech-Language-Hearing Case History Questionnaire 4 Oral Motor/Feeding Please tell the approximate age that your child achieved the following feeding milestones: _____ Drank from a sippy cup _____Consumed mashable table foods _____Drank from an open cup _____Consumed a variety of food textures _____Consumed solids
Pediatric Audiology Case History
https://www.wichita.edu/academics/health_professions/slhclinic/documents/Peds_Aud_case_history_form.pdf
The following questions are designed to help us evaluate your child’s auditory system. Please answer them as accurately and completely as possible. If a question does not apply please write NA. 1. What is the primary reason for this appointment? _____ _____ 2. Do you feel your child’s hearing is stable or does it fluctuate?
Audiology Adult Intake Questionnaire
https://www.wichita.edu/academics/health_professions/slhclinic/documents/Audiology_Adult_Case_History.pdf
Hearing Aid History 1. Do you currently wear hearing aids? Yes No If so, how long have you been wearing hearing aids? _____ 2. How old are your current hearing aids? _____ 3. Are you generally satisfied with your hearing aid? Yes No If no, please explain: _____ _____ HHIE – Screening Instructions: The purpose of this scale is to identify the problems your hearing loss may be …
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