MEDICAL EVALUATION OF SUSPECTED HEARING PROBLEM

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MEDICAL EVALUATION OF SUSPECTED HEARING PROBLEM Powered By Docstoc
					                                                      KNOX COUNTY SCHOOLS
                                              System-Wide Screening – Hearing Services
                                                  101 East Fifth Avenue – Room 202
                                                     Knoxville, Tennessee 37917

                          MEDICAL EVALUATION OF SUSPECTED HEARING PROBLEM




Student                                                                           Date of Birth     /         /

School                                                                            Grade



Dear Parent:

Your child’s hearing was tested at school recently by a Knox County Schools audiologist. The attached results indicated
that he/she should be seen by your doctor or ear specialist.

Please take this form with you when you go for the appointment. Have the doctor complete this form and return it to us
in the enclosed envelope. This will assist us in serving your child effectively.

If you have questions or concerns, you may contact me at 594-3722. Your prompt attention to this form is appreciated.




                                                                , Audiologist CCC-A
                        Knox County Schools                                                       Date




BELOW TO BE COMPLETED BY DOCTOR

MEDICAL REPORT – IMPRESSIONS & RECOMMENDATIONS




          Physician's Signature                                      Address                             Date of Exam




SWS–H–2 (5/93)