Patient Name ____________________________ Date _____________________

1) How do you know when your child has an infection? (Circle all that apply)
A. fussy
B. pulls at ear(s)
C. won’t eat
D. runny nose
E. visible drainage out of ear
G. fever
H. none of the above; the doctor tells me
I. other ___________________________________________

2) What do you do when your child has an infection?
A. give a cold medicine
B. get an antibiotic
C. other __________________________________________

3) Please list the antibiotics you have given your child for ear infections in the last year.
Name of Medication Date Started Date Ended
A. ______________________________ __________________ ____________
B. ______________________________ __________________ ____________
C. ______________________________ __________________ ____________
D. ______________________________ __________________ ____________
E. ______________________________ __________________ ____________
F. ______________________________ __________________ ____________
G. ______________________________ __________________ ____________
H. ______________________________ __________________ ____________
I. ______________________________ __________________ ____________

4) Do you believe your child’s hearing is affected? Yes / No

5) Do you believe your child’s speech is affected? Yes / No

6) Has your child’s eardrum ruptured? Yes / No

7) Does your child have nasal blockage? (Circle all that apply)A. No
B. Yes, with snoring
C. Yes, with mouth breathing
D. Yes, with snoring and stopping breathing at night

8) Does your child go to sleep with a bottle or pacifier at night or nap time? Yes/No

9) Is your child exposed to tobacco smoke? Yes/No

10) What other family members have had problems with ear infections? (Circle all that apply)
A. mom
B. dad
C. sister or brother
D. aunt
E. uncle
F. grandparents

11) Is your child in daycare? Yes/No
How many other children are enrolled? _________