Auditory Addendum

Auditory Addendum
Client Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Current auditory concerns:*
Client has a history of or currently experiences:*

Hearing lossEar infections/chronic fluidSpeech articulation delayLanguage delayDizzinessTinnitus (ringing in ears)Distracted by background noiseFrequently misunderstands what is saidDifficulties with readingDifficulties with spellingNone of the above
Additional information:
I give permission for any A Chance To Grow, Inc. clinic that may now or in the future be involved with this client, to share information as well as this health history with the involved clinics.
Client or Guardian Signature:*

Clear
Date:*

MonthDayYear
Should be Empty: