Hearing Screening Referral Letter

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Name___________________________________

Dear Parent:

In keeping with the recommendations of the Minnesota Department of Health, your child's school class was screened for hearing on ___/___/___ and rescreened on ___/___/___.

Your child was unable to hear all of the screening sounds. Although the results do not definitely mean your child has a hearing problem, you are urged to take him/her to your physician and/or audiologist for further hearing evaluation.

Please take this letter with you when your child is examined and ask the examiner to complete the bottom half.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

See the attached screening audiogram or tympanogram.

Please complete this portion of the form and send it at your earliest convenience to:

____________________________________________

____________________________________________

____________________________________________

I have examined ________________________ and find the following:

MEDICAL:
Normal hearing
Medically treatable
Not medically treatable
Outer ear
Middle ear
Inner ear
Refer to audiology
Further comments
____________________________
____________________________
____________________________

Signed: ______________________
Date: _______________________

AUDIOLOGICAL:
Normal hearing
Conductive hearing loss
Mixed hearing loss
Sensorineural hearing loss
Refer to physician
Amplification evaluation
Further comments
_____________________________
_____________________________
_____________________________
_____________________________

Signed: _______________________
Date: ________________________


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