Patient Intake Form - Child
Child's Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Social Security #
Parent/Caregiver Name
Well Baby or NICU Nursery?
Well Baby
Nicu
For How Long?
Insurance Card (Front & Back)
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Parent Contact Details
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Preferred Email
*
example@example.com
Secondary Email if Required
example@example.com
Do You Consent to Receive Text & Email Communication from Audicles?
*
Yes
No
Insurance Company
Insured Name
Family Doctor or Primary Care Physician
*
Back
Next
Hearing Details
Reason for Today's Visit
*
How Was Your Child Referred to Audicles?
*
Do You Have Concerns About Your Child's Hearing?
*
Yes
No
Please Explain
Did Your Child Pass Their Newborn Hearing Screening?
*
Yes
No
Which Ear(s) Did Not Pass the Screening?
Left
Right
Both
Does Your Child Have Any History of the Following? Select All That Apply
Ear infections
Fluid in the ear
Ear surgery
Other
When Did This Occur?
How Long Did It Occur?
In Which Ear(s)?
Left
Right
Both
Is There a Family History of Hearing Loss?
*
Yes
No
Which Family Member(s)?
Does Your Child Have a Diagnosis of Other Relevant Health/Medical Conditions?
*
Yes
No
Please Explain
Back
Next
Speech, Language Etc.
Does Your Child Have Speech?
*
Yes
No
At What Age Did They Say Their First Word?
Is Their Speech Intelligible?
Yes
No
Does Your Child Respond (eg. Head Turn) When Their Name is Called?
*
Yes
No
Does Your Child Understand What You Say to Them?
*
Yes
No
Does Your Child Follow Simple Commands?
*
Yes
No
Does Your Child Receive Speech/Language Therapy?
*
Yes
No
Where?
Start Date
-
Month
-
Day
Year
Date
Does Your Child Receive Occupational Therapy?
*
Yes
No
Where?
Start Date
-
Month
-
Day
Year
Date
Release of Records
I consent for Audicles Hearing Services to release my child’s hearing healthcare records to the following persons or entities:
Submit
Should be Empty: