Get Newborn Hearing Screening Outpatient Follow-up Report Form

Completing the Newborn Hearing Screening Outpatient Follow-Up Report Form online is a crucial step in ensuring that newborns receive timely hearing assessments. This guide will walk you through each section of the form to help you provide the necessary information accurately and efficiently.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. In the 'Patient Information' section, fill in the child's name using the format 'Last, First'. Specify the gender by selecting either 'Female' or 'Male'. Enter the child's date of birth in the designated field.
3. Provide the child’s address, city, and state. Next, enter the mother’s name (Last, First) and her contact phone number.
4. If applicable, enter the caregiver's name, their relationship to the child, and their phone number. Then, fill in the primary care physician’s name.
5. Indicate the language spoken in the home and the primary clinic's name and city.
6. In the 'Appointment Change' section, include the date of the appointment and mark whether it has been canceled.
7. Proceed to the 'Assessment Results' area. Indicate whether this is the first outpatient visit and provide the date of service and the audiologist’s name.
8. For the screening results for both the right and left ears, select the applicable options for the following tests: AABR, DPOAE, TEOAE, and tympanometry. Ensure to check all results appropriately.
9. If any results indicate a referral, make a note to schedule a diagnostic audiology appointment as soon as possible.
10. In the 'Referrals and Appointments' section, check all that apply and provide details of the audiology and otolaryngology clinics when known. Include the appointment dates.
11. Lastly, use the notes section for any additional comments or details before saving your changes.
12. Once completed, you can save the form, download it, print it, or share it as necessary.

Start filling out the Newborn Hearing Screening Outpatient Follow-Up Report Form online today.