Special Services, Johnson County and Surrounding Schools
Transcripción
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