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听力档案

听力档案
听力档案

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病案号_____________

登记日期_____________

姓名:________性别:男___女___ 年龄:________出生______年_月___日民族:_____籍贯:_____省____市_____县出生地:______________________住地(通讯地址): _______________________________________父姓名:________ 年龄______职业______文化程度______听力情况_________ 母姓名:________ 年龄______职业______文化程度______听力情况_________ 病史

一、耳聋史

1、A 自幼听力言语障碍;B 自幼听力正常,言语障碍;C 自幼言语不清,

听力略障碍;D 出生后正常听力__________后听力逐渐漳碍。

2、何时发现耳聋:_______________________________________

3、对何种声音可听见:A 打雷声;B 鞭炮声;C 汽车喇叭声;D 大声说活;

E 拍手声;

F 普通讲话声

4、曾去何地诊治:第一次_______医院时间__________________________

经过_____________________________________________

第二次_______医院时间__________________________

经过_____________________________________________ 5、是否配过助听器:左耳_______右耳_______型号类型:左______右_______

效果: A 好 B 一般 C 没效

6、进人语言训练机构:A 省 B 市 C 地区 D 县

家庭康复训练情况:A 从未训练过B 聋校

7、耳聋时伴有何其他症状__________________________________________

二、家族史:________________________________________________________ ___________________________________________________________________

三、出生史

1、妊娠期情况

母亲(3 一4 个月)传染病史:________________________________________ 母亲耳中毒药物史(链霉素、庆大霉素、卡那霉素、新霉素、其他)用药原因__________________________ 剂量_________________________ 有何反应________________________________________________________ 有无用保胎药_______药名:_______________________________________ 有无子痫(高血压)______________________________________________ 妊娠反应: A 轻 B 中 C 重 D 无反应

妊娠外伤史:________________________________________________________ 妊娠期其他疾病:____________________________________________________ 2 、分娩情况

足月顺产:___________早产:__________月份:_____________

难产:________助产(产钳): _______引产:______剖腹产:_______

出生时缺氧:有____无_____体重______脐带绕颈:有____无_____

四、个人史:

1 、耳聋前传染病史(患过某病: )

是否患过:脑膜炎大脑炎伤寒斑疹伤寒麻疹流感

肝炎猩红热腮腺炎小儿麻疹风疹水痘百日咳

肺炎疟疾腹泻中耳炎高烧黄疽患病时情况:______________________________________________________ __________________________________________________________________ 病程及治疗情况:___________________________________________________ __________________________________________________________________

2、耳聋前耳中毒药物史:

是否用过:链霉素庆大霉素卡那霉素新霉素奎宁

水杨酸小诺霉素红霉素洁霉素

用药原因:________________________________________________________ 剂量:________________________________________________________

时间:________________________________________________________ 听觉障碍__________________________________________________________

平衡障碍__________________________________________________________

3、头外伤史_______________________________________________________

4、药物过敏史_____________________________________________________

5、X光接触史_____________________________________________________

6、全身情况(神经系统、畸形)_____________________________________

7、耳聋治疗及疗效_________________________________________________

8、看话能力_______________________________________________________

9、学语模仿能力、发音能力_________________________________________

10、精神智力状况__________________________________________________

ll、心理状况______________________________________________________检查

一般情况:___________________________________________________________ 鼻咽喉部所见:_______________________________________________________ 耳部所见:___________________________________________________________右耳:

耳廓正常畸形

外耳道通畅盯聆分泌物(水样、浆液浓性)

耳模完整内陷粘连充血肥厚钙斑穿孔活动(好、不好)中耳正常积液水肿肉芽

乳突正常红肿压痛空洞胆脂瘤

咽鼓管通畅不通压力

左耳:

耳廓正常畸形

外耳道通畅盯聆分泌物(水样、浆液浓性)

耳模完整内陷粘连充血肥厚钙斑穿孔活动(好、不好)中耳正常积液水肿肉芽

乳突正常红肿压痛空洞胆脂瘤

咽鼓管通畅不通压力

听力检测项目情况:

诊断:

1、_____________________________________________________________

2、_____________________________________________________________ 处理意见:

_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

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