Early Childhood Hearing Screening Worksheet

(Also used for Child and Teen Checkup)
[Note: WNL = Within Normal Limits]

Printer-Friendly Version

Name:
Age:
  Yrs Mos
Screen Rescreen
Dates:
Problem Noted: NO YES NO YES

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 +)        

PURE TONE:

Screen: Head Cold WNL Rescreen
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear        
Left Ear        
Rescreen: Head Cold WNL Rescreen
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear        
Left Ear        
Threshold in HL: Head Cold Date ___ / ___ / ___
Frequency (Hz) 500 1000 2000 4000
Right Ear (dB) (dB) (dB) (dB)
Left Ear (dB) (dB) (dB) (dB)
Reliability: Good Fair Poor

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)?

Printer-Friendly Version
Early Childhood Hearing Screening Worksheet (42 kb / 1 page)PDF Icon
To view PDF files, you will need Adobe Acrobat Reader (free download from Adobe web site).