Early Childhood Hearing Screening Worksheet
(Also used for Child and Teen Checkup)
[Note: WNL = Within Normal Limits]
A. Risk Factors (29 days to 2 years)
|B. Hearing History (all ages)|
|C. Auditory Checklist (birth to 36 mos.)|
|D. Visual Inspection/Otoscopy (all ages)|
|E. Tympanometry (6 mos. +) If problems noted attach tympanogram|
|F. Pure tone (3 years +)|
HEARING HISTORY (all ages):
1. Is there concern that this child has a hearing problem?
2. Are there any childhood hearing problems in the family of either the child's mother or father?
3. Does child have history of middle ear disease and/or tubes?
4. Has child had head trauma with concussion, skull fracture or loss of consciousness?
5. Has child been hospitalized with a serious illness (i.e. kidney, meningitis)?
Childhood Hearing Screening Worksheet (42 kb / 1 page)
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