Special Services, Johnson County and Surrounding Schools

Special Services, Johnson County and Surrounding Schools

Special Services, Johnson County and Surrounding Schools
H-6 (Spanish)
Estudiante: ________________________________________________ Fecha de Nacimiento: ________________________
Escuela:_________________________ _______________ Grado: ___________ Fecha: ___________________________
Queridos Padres:
La evaluacion de la audiencia de su nino indica que el/ella puede tener difficultades escuchando. Usted ya puede estar enterado
de esta condicion, sin embargo, como cuestion de precaucion se sugiere que usted consulte con un medico para determinar que
esta causando la difficultad en la audiencia al presente tiempo. Cuando usted consulte con el medico, informele por favor que el
necesita llenar este formulario y que lo regrese en el sobre de respuesta que esta adjunto. Si usted tiene algunas preguntas, por
favor communiquese conmigo en la escuela de su nino.
_________________________________________________
Patologo de la Lengua del Discurso
PHYSICIAN'S REPORT
EAR EXAMINATION
AUDITORY CANAL
OCCLUDED
R L
  NO FINDINGS
  FINDINGS 
OCCLUDED BY:
R L
  PARTIALLY
  COMPLETELY
R L
  CERUMEN
  FOREIGN BODY
R L
  INFLAMMATION
  OTHER(DESCRIBE)
_____________________________________
R L
  NO FINDINGS
  FINDINGS 
  NOT VISIBLE
R L
 
 
 
 
TONSILS:
 REMOVED COMPLETELY
 TONSILS PRESENT (NORMAL)
 TONSILS PRESENT (ENLARGED)
ORAL PHARYNX:
 NO FINDINGS
 CLEFT PALATE
 REPAIRED
DRUM:
DULL
BULGING
RETRACTED
PERFORATED
R L
  SCARS
  OPAQUE
  RED
  OTHER ___________________________________________________
NOSE AND THROAT EXAMINATION
 UNREPAIRED
 HEAVY POSTNASAL DISCHARGE
 MOUTH BREATHING
 OTHER: ____________________________________________
_____________________________________________
DIAGNOSIS






CANAL OBSTRUCTIONS
ACUTE OTITIS MEDIA
CHRONIC OTITIS MEDIA
DRUM PERFORATION
ALLERGIES
COMMENTS:




Mild
Moderate
Severe
CONDUCTIVE HEARING LOSS



SENSORI-NEURAL HEARING LOSS



MIXED HEARING LOSS



OTHER (DESCRIBE) ______________________________________________________
RECOMMENDATIONS / TREATMENT





Medication
(
Return to this office in (
Further exam by ear, nose, throat specialist
Complete audiological evaluation
Tonsillectomy & Adenoidectomy
)
)
 Ventilation tube (re) insert [Left -- Right]
 Cerumen removal
[Left -- Right]
 Repeat audiogram at school in (
)
 Other: ____________________________________________________
RELEASE OF INFORMATION
DATE OF EXAMINATION: ___________________________________________
MONTH
DAY
YEAR
CONSENT OF PARENT OR GUARDIAN
PRINTED OR STAMPED PHYSICIAN'S NAME:
I agree to release the above information re: my child to appropriate
health and/or school officials.
_________________________________________________________________
Office Address:
____________________________________________________________
Parent or Guardian Signature
Enclosures:
Pure Tone Audiogram (H-7),
_______________________________________________
_______________________________________________
Office Phone:
_______________________________________________
Self-addressed envelope
500 Earlywood Drive, Franklin, IN 46131 Phone: 317.736.8495 Fax: 317.736.6967 www.ssjcs.k12.in.us