forms & resources

To save time at your first visit to Central Illinois Hearing, please download, print, and complete the applicable forms.  Please note:  every new patient must complete the New Patient Info form.  Choose appropriately whether to complete the Pediatric or Adult Case History form.


New Patient Information

Characteristics of Amplification Tool (COAT)

Adult Case History

Consent Form

Assignment of Benefits

Pediatric Case History

Privacy Policy

Hearing Loss Information

Signs Of A Hearing-Loss Problem

Hearing loss can occur at any age. It is often such a gradual process that the person with the impairment is the last one to realize there is a problem. If you think you or a family members has a hearing problem, consult a hearing health professional and arrange to be tested as soon as possible.

Many types of hearing loss are only temporary and can be treated by your hearing health professional. Other types of hearing loss are permanent but still can be improved with the proper hearing aid and training.

If you answer “no” to any of these questions, have your child’s hearing tested. Early detection of a hearing problem is important to your child’s proper development.

-Birth to 3 months: Is your baby startled by sudden loud sounds?
-3 to 6 months: Does your baby respond to your voice? Does your baby enjoy rattles or other noise-making toys?
-6 to 12 months: Does your baby respond to his or her name?
-12 to 18 months: Does your baby understand “No” or “Bye-bye”? Can your baby imitate simple words or sounds?
-2 years: Can your child point to familiar objects when you ask? Has your child started to talk?

Signs Of A Hearing-Loss In Older Children

If you answer “yes” to any of the following questions, a hearing test is suggested.
- Does your child have problems paying attention in school?
- Does your child have a problem understanding if you speak from behind?
- Do you think you child can hear, but only when he or she wants to hear?
- Do you think your child speaks too loudly?

Signs Of A Hearing-Loss In Adults

If you answer “yes” to any of these questions, you should have your hearing tested.
- Do you think other people mumble or speak too softly?
- Do you hear better with one ear than with the other?
- Do friends and family tell you that they have to repeat things for you?
- Do you have difficulty hearing when you are with a large group of people?
- Do people complain that you turn up the TV too loudly?
- Have you ever said, “I can hear you; I just didn’t understand what you said?”
- Do you avoid certain activities because it is too difficult to hear?

Signs of Speech-Language/Hearing Problems

Speech problems in children may be evidenced by delayed development in comparison to other children of the same age. Lack of clear, concise communication may indicate a problem. Hearing disorders in children may be forewarned by an infant’s failure to react to noises and failure to follow simple commands by age two.

In adults, sound distortion and lack of clarity or a subdued quality in the sounds may indicate a hearing problem.

Voice problems in adults may be shown by persistent huskiness or coughing.

Speech, Language, and Listening Milestones

The following are milestones, the points of progress children should reach in their own style, at their own pace.

Birth to 3 Months
-Reacts to sudden noises by crying or jerking body
-Reacts to familiar objects, such as a bottle, or familiar people such as parents
-Differentiates the cry of pain from the cry of hunger
-Coos, begins to form prolonged vowels with changes in intonation (“Ahhhhh-AH-ahhh!)
-Watches objects intently

3 to 6 Months
-Begins to babble, using syllables with a consonant and vowel (“baa-ba-BA-ba-ba!”) and uses intonation changes
-Laughs and shows pleasure when happy
-Turns the head to see where sound is coming from
-Uses a louder voice for crying and babbling than before
-Shows delight when bottle or breast is presented

6 to 9 Months
-Begins to comprehend simple words such as no and looks at family members when they are named
-Babbles with a singsong pattern at times
-Controls babbling to two syllables, which sometimes sounds like words such as “Mama,” although meaning is, typically, not understood by the baby yet.
-Understands facial expressions and reacts to them
-Attempts gestures to correspond to a pat-a-cake and bye-bye
-Shakes head to show no
-Uses more and more sounds when babbling, such as syllables with da, ba, ka, pa, ma and wa

9 to 12 Months
-Has fun imitating simple sounds and babbling
-Begins to say “Mama” and “Dada” with meaning
-Begins to understand that words represent objects
-Jabbers loudly
-Responds to music
-Gives or seeks a toy or common object when requested
-Imitates common animal sounds
-Gestures and whines to request something
-Looks directly at the source of sound immediately

12 to 18 Months
-Understands 50 to 75 words
-Uses 3 to 20 “real” words, even if not produced completely clearly
-Points to known objects when named
-Points to a few simple body parts, such as eyes and nose
-Babbles and uses nonsense words while pointing
-Follows simple one-step commands
-Uses words like more, all-gone, mine and down
-Imitates words
-Pronounces some understandable words
-Typical utterances at this age:
"doppit” (stop it)
“Appuh” (apple)
“Gimme da!” (give me that)
“Baw” (ball)
“Too-duh” (toothbrush)

18 Months to 2 Years
-Comprehends about 300 words
-Uses about 50 recognizable words, mostly nouns
-Speaks with mostly “real” words now
-Wants to hear the same stories over and over
-Uses rising intonation pattern to show a question
-Shakes head to answer yes/no questions (“Do you want more milk?”)
-Follows two related commands (“Go upstairs and get your bottle.”)
-Begins to use some verbs (go) and adjectives (big)
-Joins two related words to make one word (geddown for get down or stoppit for stop it)
-Starts to ask, “What’s ’at?” (what’s that)
-Talks about what is happening now
-Tells you his or her name when asked
-Joins in nursery rhymes and songs
-Speaks with many pauses between words
-Typical utterances at this age:
“Dawddie bad!” (Doggie bad!)
“Go ‘way!” (Go away)
“No, Mommy.”
“See...horsey,... Daddy!”
“Danwit... goo’... Mommy.” (Sandwich good, Mommy.)
“Nigh’nigh’ now?” (Night-night now?)
“Go dore?” (Go store?)

2 to 3 Years
-Understands about 900 words
-Uses about 500 words
-Pronounces words more clearly
-Engages in eye contact during conversations with occasional prompting
-Makes frustrations known more with words and less with temper tantrums and crying
-Sits and listens to stories for 10 to 20 minutes
-Identifies a boy and girl
-Answers simple questions beginning with who, where, and what (“Who drives a firetruck”)
-Understands prepositions such as in, on and so forth
-Begins to ask yes/no questions (“It raining?)
-Talks to self while playing
-Begins to use function words such as is (“Ball is red”)
-Begins to use past tense verbs (walked, kicked)
-“Stutters” when excited sometimes
-Pronounces these sounds consistently in words: m, n, p, f, b, d, h, y, m
-Typical utterances at this age:
“Daddy’s tar...so big!” (daddy’s car so big)
“Mommy put dat downstairs?” (Mommy put that downstairs?)
“On no! My-my-my jeth iddirty!” (Oh no! My dress is dirty.)
“You wanna ‘nana, An Pat?” (You want a banana, Aunt Pat?)
“I doe wannit!” (I don’t want it)
“Mattchew’s yeg is beedin’!” ( Matthew’s leg bleeding)
“Duh wabbit eated duh cawit!” (The rabbit eated the carrot)

3 to 4 Years
-Begins to use is at beginning of questions
-Understands about 1,200 words
-Uses about 800 words
-Uses eye contact more consistently during conversations
-Asks many questions, usually what or who questions
-Understands time concepts such as morning, lunch time, tonight
-Understands positional words such as in front, behind, up and down
-Starts to use s on verbs to show present tense (he runs)
-Uses contractions won’t and can’t
-Uses and
-Uses plurals consistently (books, toys)
-Use are, or contracted form, with plural nouns (“Kids’re playing outside”)
-Initiates conversations, making comments or observations
-Asks many questions, sometimes the same one several times in a few minutes
-Follows a simple plot in children’s storybook
-Sits down and does one activity for 10 to 15 minutes
-“Stutters” less frequently
-Pronounces the beginning, middle and ending sounds in words, except for consonant blends (e.g., bl, fr cr)
-Uses k and g sounds correctly, but s may still be somewhat “lispy” sounding; r and l may be distorted: v, sh ch, j and th still may not be used consistently
-Typical utterances at this age:
“The bider its cwawlin’ up duh twee!” (The spider is crawling up the tree)
“Dad, the tiddy-tat breaked the diss.” (Dad, the kitty-cat breaked the dish.)
“Is Mom-Mom comin’ today?”
“Where’s the hop-sital?” (Where’s the hospital?)
“Yesterday my dog Wainbow ate six bixkits.” (Yesterday, my dog Rainbow ate six biscuits)

4 to 5 Years
-Comprehends 2,500 to 2,800 words
-Uses 1,500 to 2,000 words
-Speaks clearly most of the time
-Describes pictures with complete sentences
-Makes up stories
-Uses all pronouns correctly: he, she I, you, them
-Describes what you do with common objects
-Speaks in complex sentences that often run together
-Uses past, present and future tenses of verbs (sit, sitting, sat, will sit)
-Uses irregular verbs (drank, ate) and irregular nouns (men, children) somewhat consistently
-Follows three-step commands
-Explains events that took place in the past with accurate detail
-Knows common opposites such as big/little, heavy/light
-Plays dramatically and chats a lot
-Repeats a sentence with 10 to 12 syllables
-Listens and attends to stories, conversations, and movies
-Mispronounces s, r, th, l, v, sh ch j and blends
-Typical Utterances at this age:
“Daddy, I wanna go to Joey’s house after lunch ‘cause he’s got this great new truck I wanna play wif (with).”
“Is this your pocketbook? Could I thee (see) what you have inside it?”
“Do you have any gum in there?”
“I found all these wed (red) marbles on Jose’s floor, Mommy. Can I have them? I want to play with them for a little while.”
“Look at all those gwirrels (squirrels) runnin’ across the road!”
“Johnnie cutted the paper all up.”

5 to 7 Years: The Refinement Years
-Refines pronunciation, sentence structure, word use, attention span for listening, and memory for directions
-Increases vocabulary; incorporates new words into spontaneous speech
-Retells stories: explains experiences more, in a cohesive, sequential manner and with greater elaboration
-Participates in group discussions and takes turns in conversation; comments are more relative to topic being discussed
-Begins to learn language relationships: opposites (big/little, sad/happy), synonyms (big/large, sad/unhappy), associations (bread/butter, pencil/eraser), and classification (shirt/pants/socks belong in the category of clothing)
-Typical utterances at this age:
“Last week Daddy took me and Levonne to the Bronx Zoo.”
“You shoulda seen the monkeys and elephants!”
“She has ‘amonia and she’s really sick, so she has to stay in the hopsital for another week.”

When children begin school, language is translated into written symbols through spelling and comprehended through reading. Written words are developed into sentences and stories. Children whose oral language is deficient (beyond the typical errors a child of this age displays) are at risk for reading, writing and spelling problems. However, teachers are trained to teach children in a way that best suits their individual needs. So, although communication problems may present a challenge, they certainly can be managed with a little bit of teamwork, creativity, and patience!

7 Years to Adolescence
-Possesses a functional and abstract language system
-Shows age-appropriate skills in reading, writing, speaking and listening
-Joins sentences to form coherent, descriptive thoughts and stories; listeners are not left confused
-Masters word relationships (synonyms, antonyms, association, classification, etc.)
-Pronounces multisyllable words correctly once practiced a few times
-Comprehends information heard and read when adequately taught and explained
-Understands and uses more idioms (pain in the neck, out of your mind)
-Understands plots with increasing depth and complexity when read or watched in a movie or television show
-Essentially, a child’s language at this age mirrors an adult’s, but with more simplicity.

Preventing Cognitive Decline:  Hearing Interventions Possible

Chronic conditions such as age related hearing loss and senile dementia are becoming more prevalent and costly in terms of healthcare burden and expenditures. An estimated 5.2 million older adults had Alzheimer’s disease in 2014, with prevalence projected to rise to 6.7 million by 2025. Like age related hearing loss, detection of dementia is a problem in routine medical practice, with the diagnosis often missed.

The devastating effects and medical expenditures associated with dementia care have served as the impetus for research devoted to uncovering modifiable determinants and risk factors. Treating hearing impairment may in fact serve as a buffer against the onset of cognitive decline.

People with a mild, moderate or even severe hearing loss have a twofold, threefold and fivefold increased risk respectively, of dementia compared with people who have normal hearing. Bottom line, Good hearing can lead to a healthy physical, mental state. Got your hearing checked?

Hearing Disorder Information

Hearing-Loss Facts

Hearing loss affects the communication ability of at least 24 million Americans – over half of whom are over the age of 65 – causing loneliness, anxiety and isolation. Yet, it is estimated that only 4 to 5 million people wear hearing aids to help overcome their hearing problems.

One reason is that hearing loss is invisible and almost gradual and painless. There are no physical warning signs, except in some cases where ringing in the ears (tinnitus) may be present. It is typical for a person with a mild to moderate hearing loss to be unaware of their problem, even though family and friends may be aware of the problem.

Hearing loss ranks third among disabilities in older Americans. This rate is increasing at a faster rate due to the aging of the U.S. population.

The causes of hearing problems vary greatly according to age. Some hearing problems are due to genetic factors, while others are caused by infectious diseases, excessive noise exposure, ototoxic drugs, presbycusis (aging process) and trauma.

How We Hear

Sound waves are collected by the outer ear and channeled along the ear canal to the eardrum. When sound hits the eardrum, the impact creates vibration, which in turn causes the three bones in the middle ear to move. The smallest of these bones, the stirrup, fits into the oval window between the middle and inner ear. When the oval window vibrates, fluid in the inner ear transmits the vibrations into a delicate, snail-shaped structure called the cochlea.

In the inner ear, thousands of microscopic hair cells are bent by the wave-like action of fluid inside the cochlea. The bending of these hair cells sets off nerve impulses that are passed through the auditory nerve to the hearing center of the brain. The center translates the impulses into sound memories that the brain can recognize.

Approximately 10 percent of all hearing losses may be helped medically or surgically. The remaining 90 percent may find help in the form of hearing aids or assistive listening devices.

Types Of Hearing-Loss

Conductive loss is produced by injury to or problems with the bones, eardrums and membranes that carry sound from the external ear through the middle ear to the inner ear. Generally, conductive disorders affect children and can be medically or surgically treated by an otolaryngologist or ear, nose and throat specialist (M.D.).

Sensorineural is also known as nerve deafness, and is a loss in which all the mechanisms (outer and middle ear) are intact but a deterioration of the inner ear is present (specifically the hair cells). This may be caused by the natural aging process or degeneration of the nerves leading from the inner ear to the brain.

Sensorineural losses cannot be surgically or medically repaired.

Mixed is a loss that contains elements of both a conductive and sensorineural hearing loss.

Helpful Links


Springfield Office

4000 Westgate Drive
Springfield, IL 62711
Phone (217) 501-4105

Jacksonville Office

1515 West Walnut #4
Doctor’s Plaza
Jacksonville, IL 62650
Phone (217) 953-0066