Child's name (Last, First, MI): Gender: Male Female
DOB:
Place of Birth: Home Hospital (name):
Mother's Name: Father's Name: Home Address (City, State, Zip): Phone: Primary Care Physician
Date of Screening: Device Type:
Name & Agency of Screener:
Technology Used: DPOAE TOAE AABR
Left Ear Results: Pass Refer Not Screened (list reason): Right Ear Results: Pass Refer Not Screened (list reason):
Date of Assessment: Screened/Tested by:
Testing methods used (mark all appropriate):
ABR AABR DPOAE TOAE Tymp 226Hz Tymp 1000Hz BOA VRA CPA
Type of Hearing Loss:
Normal Auditory Neuropathy Conductive (transient) Conductive (permanent) Mixed Sensorineural Not Yet Determined
Degree of Hearing Loss:
Mild Moderate Severe Profound Unknown Severity
Amplification Type: Air Conduction Bone Conduction Cochlear Implant
Amplification Style: BTE ITE/Canal
