Baby Hearing Screening

Please note the following: We are a cash practice, with all fees required to be paid upfront on the day of the screening. We will issue you with an account, complete with the correct ICD 10 codes for you to submit to your medical aid for re-imbursement. Please note that we are a separate practice from the clinic. Member remains liable for payment of the account. Further, the member will be liable for all legal costs incurred in the recovery of the outstanding money.

Please complete with the Main Members Details: Person responsible for the account

Patient Status

New
Current

Surname*

First Name*

Initials

Title

ID Number*

Religion

Home Language

Tel Work

Tel Home

Cell Number: Dad

Cell Number: Mom

Fax Number

Home Address

Postal Code

Postal Address

Postal Code

Email*

Medical Aid

Medical Aid Option

Medical Aid Number

Hospital Number*

Baby Dependant Number

Baby Details

Mother's Full Name and Surname*

Baby's Full Name and Surname*

Sex

Male
Female

Date of Birth*

Time of Birth

:

Duration of pregnancy

Type of birth

Natural
C/Section

Birth weight

Apgar scores

Replace underline with score

Pediatrician*

I,*

I hereby consent to a hearing evaluation on my baby, and consent to the report being forwarded to the attending paediatrician.

I confirm that I have read, understand, acknowledge and accept full responsibility of this account.

Signature*

Date*

For Audiologist Use

1. ls there a history of hearing loss in children in your family?

Yes
No
Uncertain

Please describe this history

2. ls there a history of Retinis Pigmentosa (progressive blindness) in your family?

Yes
No
Uncertain

3. Do you have a close relative with a syndrome?

Yes
No
Uncertain

4. Did you have any of the following during your pregnancy:

Cytomegalovirus (CMV)

Yes
No
Uncertain

Toxoplasmosis

Yes
No
Uncertain

German Measles

Yes
No
Uncertain

Other childhood diseases

Yes
No
Uncertain

Herpes simplex

Yes
No
Uncertain

Syphilis

Yes
No
Uncertain

HIV/AIDS

Yes
No
Uncertain

5. Did you have diabetes during your pregnancy?

Yes
No
Uncertain

6. Did you take any medication during pregnancy? (excluding vitamins)

Yes
No
Uncertain

Details of medication

Please describe this history

7. Did you experience severe bleeding during your pregnancy?

Yes
No
Uncertain

8. Are there family members (e.g. husband/other child) with chronic middle ear problems. sinus problems or allergies?

Yes
No
Uncertain

Disorders/ Infections

Feeding/Swallowing and Gastrointestinal Disorder

Hematological Disorder

Hyperbilirubinemia at serum levels requirinq blood transfusion

Central Nervous System Disorder

Ototoxic medication

Respiratory System Disorder

Mechanical ventilation

Cardiovascular System Disorder (CVS)

Craniofacial anomalies

Congenital infections

Peri-and postnatally acquired infections

Testing

Testing Protocol*

STATE OF BABY DURING EVALUATION:

OTOACOUSTIC EMISSIONS - RIGHT EAR

OTOACOUSTIC EMISSIONS - LEFT EAR

AUDIOLOGIST PLEASE INDICATE:

Diagnostic OAE at 3 months
Follow-up in 6 weeks
Follow-up in 6 months
Screening ABR
Annual hearing evaluation
Other
Results conveyed and pamphlet given

Reasons

ABR Screening

STATE OF BABY DURING EVALUATION:

SCREENING ABR - RIGHT EAR:

SCREENING ABR - LEFT EAR:

AUDIOLOGIST PLEASE INDICATE:

Diagnostic OAE at 3 months
Diagnostic ABR
Annual Hearing Evaluation
Other
Results conveyed and pamphlet given

Reasons

Due to additional risk factors a screening Auditory Brainstem Response (AABR) test was completed in order to exclude retrocochlear pathology.

ABR and OAE Screening

STATE OF BABY DURING EVALUATION:

SCREENING OAE RIGHT EAR:

SCREENING OAE LEFT EAR:

SCREENING ABR RIGHT EAR:

SCREENING ABR LEFT EAR:

AUDIOLOGIST PLEASE INDICATE:

Diagnostic OAE at 6 months
Follow up 2-6 weeks
6 month follow up
Diagnostic ABR
Annual Hearing Evaluation
Other
Results conveyed and pamphlet given

Reasons

OAE Screening

SCREENING OAE RIGHT EAR:

SCREENING OAE - LEFT EAR:

AUDIOLOGIST PLEASE INDICATE:

Diagnostic OAE at 6 months
Diagnostic OAE
Annual Hearing Evaluation
Other
Results conveyed and pamphlet given

Reasons

Billing Details

Billing details for OAE's

Additional Comments

Receipt number*

Please tick Payment Type:

Amount Paid

Audiologist*

ABR Billing Details

Additional Comments

ABR Receipt number*

Please tick Payment Type (ABR):

Amount Paid

ABR /OAE BILLING DETAILS

ABR Receipt number*

Please tick Payment Type (ABR):

Cash
Debit Card
EFT on Site
Credit Card

Amount Paid

OAE | Additional Comments

OAE Receipt number*

Please tick Payment Type (OAE):

Amount Paid

General

Date of test*

Clinic/Hospital*

Time of Test

:

Audiologist's Signature*