Initial Visit Form

Email *

Students Name *

First

Last

Date of Birth *

Gender *

Male
Female

Who may we thank for referring you to All Ears!? *

Primary language(s) spoken in your home? *

Current school placement: *

Please list services your child is currently receiving: *

Ex: Speech Therapy/ECI-Conroe ISD/60min/week

Where was your child born? (home, hospital-name) *

Did your child pass the Newborn Hearing Screening? *

Where was your child’s Newborn Hearing Screening performed? (Name of Facility) *

If your child has undergone a hearing screening more than once, how many times and where? *

Date of your child’s hearing loss diagnosis: *

By whom was diagnosis made, and where? *

Current Audiologist: *

Audiologist Phone Number: *

Last audiology appointment date: *

At what age did your child begin consistent use of hearing technology? *

Right Ear: Degree of loss *

Mild
Moderate
Severe
Profound

Hearing Technology Used: *

If CI, please provide the name of your child’s CI surgeon

Does your child currently have or has s/he previously used assistive technology such as FM/DM System or streaming device? If so, what type and how often? *