Newborn Hearing Screening Follow-Up Form

Newborn Hearing Screening Follow-Up Form — Form Fields

This healthcare template includes 12 fields. Parents complete a follow-up intake form after their newborn did not pass the initial hospital hearing screening. Free to customize and use on ZenBuild.

• Parent or Guardian Name (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Baby's Full Name (text, required)
• Baby's Date of Birth (text, required)
• Referring Hospital or Clinic (text, required)
• Which Ear Did Not Pass? (dropdown selection, required) — options: Left, Right, Both
• Type of Initial Screen (dropdown selection, required) — options: DPOAE, AABR, Both
• Date of Initial Screening (text, required)
• Family History of Hearing Loss? (dropdown selection, required) — options: Yes, No, Unknown
• Other medical history or complications (long text, optional)
• I understand follow-up testing is recommended within 1 month (checkboxes, required)