Healthy Hearing Program - Special Olympics
Healthy Hearing Program - Special Olympics
Healthy Hearing Program - Special Olympics
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>Healthy</strong> <strong>Hearing</strong> <strong>Program</strong><br />
<strong>Special</strong> <strong>Olympics</strong> International<br />
Screening Follow-up Recommendations<br />
___________________________ _________________________ ____________________<br />
Athlete's Name (print) <strong>Special</strong> <strong>Olympics</strong> Event (print) Date<br />
____________________________________________ _____________________<br />
Athlete's Address (print) Athlete's Phone Number<br />
You Did Not Pass <strong>Hearing</strong> Screening Right Left<br />
You Did Not Pass Middle Ear Screening Right Left<br />
Services you received at this <strong>Special</strong> <strong>Olympics</strong> event include:<br />
Ear canal inspection <strong>Hearing</strong> screening Middle Ear screening<br />
Noise protection brochure <strong>Hearing</strong> Loss Brochure<br />
Other ________________________<br />
Recommendations<br />
See physician for ear wax removal Right Left<br />
See physician for possible middle ear problems Right Left<br />
See audiologist for evaluation of your hearing<br />
Comments ________________________________________________________________<br />
_________________________________________________________________________<br />
_________________________________________________________________________<br />
__________________________________(signature) ________________________ (print)<br />
Audiologist or HH Clinical Director<br />
54
Change language