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Hearing Follow Up

1. Please enter your child's information below:

First Name
Last Name
Parent/ Guardian Phone Number
Parent/ Guardian Email

2. What school does your child attend?

3. What grade is your child in?

4. What is the date that your child last saw an ear care professional?

5. Was your child diagnosed with any of the following? (Check all that apply)

Eustachian Tube Dysfunction
Otitis Media
TM Perforation
Cholesteatoma
Sensorineural Hearing Loss
Mixed Hearing Loss
Normal Exam
Other Please enter an 'other' value for this selection.

6. Was any treatment recommended? (Check all that apply)

7. Is there any additional information regarding your child's hearing that you would like the Allegan County Health Department to know?