Newborn Hearing Screening Audiology Follow-up Report Form · Click ABR Toneburst ABR BC ABR ASSR NB...
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NEWBORN HEARING SCREENING AUDIOLOGY FOLLOW-UP REPORT FORM FAX COMPLETED FORM AND COPY OF VISIT SUMMARY TO 651-215-6285 PATIENT INFORMATION Child’s name (last, first): Date of birth: Gender: Female Male Address, City, State: Mother’s name (last, first): Mother’s phone: Caregiver’s name/relaonship/phone (if different): Language used in home: Primary care physician: Primary Clinic Name, City: ASSESSMENT RESULTS Important: Test both ears and do not delay complete audiological diagnosis due to middle ear fluid Date of service: Audiologist: Clinic Name, City: S T SUL RE TIC GNOS DIA OR SCREENING S OSI GN A DI ALL THAT APPLY RIGHT EAR LEFT EAR AABR (screening) DPOAE TEOAE Tympanometry Pass Refer Not Done Not Done Pass Refer Not Done Pass Refer Not Done Pass Refer Not Done Peak Rounded No Peak Lg. Volume 226 Hz 1000 Hz Peak Rounded No Peak Lg. Volume REFERRALS AND APPOINTMENTS CHECK ALL THAT APPLY IF KNOWN Audiology Appointment date: Otolaryngology Appointment date: NOTES/APPOINTMENT CHANGE For more informaon on reporng, please contact [email protected] REV: 06/2018 Inconclusive Inconclusive Inconclusive Inconclusive Inconclusive Normal Elevated Absent Normal Elevated Absent Acousc Reflex Click ABR Toneburst ABR BC ABR ASSR NB Chirps Headphones/insert Non-ear specific VRA Moderate Mild Slight Normal Profound Severe Mod. Severe Normal Transient Cond. Perm. Conducve Sensorineural Degree Mixed ANSD Undetermined Type Moderate Mild Slight Normal Profound Severe Mod. Severe Normal Transient Cond. Perm. Conducve Sensorineural Mixed ANSD Undetermined Degree Type Help Me Grow Parent Support Date of referral: Date of referral: Amplificaon Ophthalmology Genec evaluaon Other (specify): Loaner Fit date: Appointment date: Appointment date: Inconclusive Not Done Pass Pass Refer Refer
Transcript of Newborn Hearing Screening Audiology Follow-up Report Form · Click ABR Toneburst ABR BC ABR ASSR NB...
NEWBORN HEARING SCREENING AUDIOLOGY FOLLOW-UP REPORT FORM
FAX COMPLETED FORM AND COPY OF VISIT SUMMARY TO 651-215-6285
PATIENT INFORMATION
Child’s name (last, first): Date of birth: Gender: Female Male
Address, City, State:
Mother’s name (last, first): Mother’s phone:
Caregiver’s name/relationship/phone (if different): Language used in home:
Primary care physician: Primary Clinic Name, City:
ASSESSMENT RESULTS Important: Test both ears and do not delay complete audiological diagnosis due to middle ear fluid
Date of service: Audiologist: Clinic Name, City:
STSU
LRE
TIC
GN
OS
DIA
OR
SCRE
ENIN
G
SO
SIG
NA
DI
ALL THAT APPLY RIGHT EAR LEFT EAR
AABR (screening)DPOAETEOAE
Tympanometry
Pass Refer
Not Done
Not Done
Pass Refer Not Done
Pass Refer Not Done
Pass Refer Not Done
Peak Rounded No Peak Lg. Volume226 Hz 1000 Hz Peak Rounded No Peak Lg. Volume
REFERRALS AND APPOINTMENTS CHECK ALL THAT APPLY IF KNOWN
Audiology Appointment date:
Otolaryngology Appointment date:
NOTES/APPOINTMENT CHANGE
For more information on reporting, please contact [email protected] REV: 06/2018
Inconclusive
Inconclusive
Inconclusive
Inconclusive
Inconclusive
Normal Elevated AbsentNormal Elevated AbsentAcoustic Reflex
Click ABR
Toneburst ABR
BC ABR
ASSR
NB Chirps
Headphones/insert
Non-ear specific VRA
Moderate
Mild
Slight
Normal
Profound
Severe
Mod. Severe
Normal
Transient Cond.
Perm. Conductive
Sensorineural
Degree
Mixed
ANSD
Undetermined
Type
Moderate
Mild
Slight
Normal
Profound
Severe
Mod. Severe
Normal
Transient Cond.
Perm. Conductive
Sensorineural
Mixed
ANSD
Undetermined
Degree Type
Help Me Grow
Parent Support
Date of referral:
Date of referral:
Amplification
Ophthalmology
Genetic evaluation
Other (specify):
Loaner Fit date:
Appointment date:
Appointment date:
Inconclusive Not Done
Pass
Pass
Refer
Refer
