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Print Form AUDIOLOGY INFANT HEARING HISTORY The following information is confidential. Today's Date: Child's Name: Age: Date of Birth: Mothers Name: Fathers Name: Prenatal and Birth History 1. Were
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01
Begin by opening the infant hearing historydoc form.
02
Fill in the child's personal information, such as their name, date of birth, and any relevant identification numbers.
03
Provide the contact information for the child's parents or guardians, including their names, phone numbers, and email addresses.
04
Indicate if the child has any siblings and provide their names and ages.
05
Fill in the medical history section, including any prenatal complications, birth-related issues, or significant health concerns.
06
Specify if the child has received any previous hearing screenings or tests.
07
Document any previous diagnoses or treatments related to the child's hearing.
08
Answer questions about the child's exposure to noise, including any loud environments or frequent use of headphones.
09
Provide information about the child's language and communication development.
10
If applicable, list any additional considerations or information that may be relevant to the child's hearing health.
11
Save the completed form and submit it to the appropriate healthcare provider or organization.

Who needs infant hearing historydoc:

01
Parents or legal guardians of infants or young children.
02
Pediatricians or healthcare providers who specialize in pediatric audiology.
03
Early intervention programs or educational institutions that provide services to infants and children with hearing loss.
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Infant hearing historydoc is a document used to track the hearing health history of an infant.
Parents or guardians of the infant are required to file infant hearing historydoc.
Infant hearing historydoc can be filled out by providing information about the infant's hearing health history and any screenings or tests that have been done.
The purpose of infant hearing historydoc is to ensure that the infant's hearing health is being properly monitored and any issues are addressed promptly.
Information such as previous hearing screenings, family history of hearing issues, and any concerns or observations about the infant's hearing should be reported on infant hearing historydoc.
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