Peds Response Form Page 2
ADVERTISEMENT
1
2Developmental Scales
(To be used with Risk IndicalOrs for Hearing Loss Checklist when performing KBH screens ages birth through four years of age.)
Name: __________________________________________
Date of Birth:_______________
Child's Chronological Age ________
Premature months Adjusted age __________
Does Your Child: (Please check questions in the appropriate age category - use adjusted age)
Birth to 4 months
Yes
No
Yes
No
Startle or cry to loud noises?
Respond to a familiar voice?
Awaken to loud sounds?
Stop crying when talked to?
Stop moving when a new sound is made?
4 to 8 months
Yes
No
Yes
Yes
No
Stir or awaken when sleeping quietly and
someone talks or makes a loud noise?
Cry when exposed to a sudden or loud sound?
Try to turn head toward an interesting sound or
when name is called?
Make several different babbling sounds?
Listen to a soft musical toy, bell, or rattle?
8 to 12 months
Yes
No
Yes
Yes
No
Stir or awaken when sleeping quietly and
Respond in some way to the direction "no"?
someone talks or makes a loud sound?
Try to imitate you if you make familiar
React to name when called?
sounds?
Turn head toward the side where a sound is
Use variety of different consonants and vowels
coming from?
when babbling? (cononical babbling:*)
12 to 18 months
Yes
No
Yes
Yes
No
Say "mama" or "dada" and imitate many words
sound came from when an interesting sound is
you say?
presented?
Respond to requests such as "come here" and
"do you want more"?
Wake up when there is a loud sound?
18 to 24 months
Yes
No
Yes
Yes
No
Try to sing?
Speak at least 20 words?
Request by name items such as milk or
Point to several different body parts?
cookies?
Respond to simple commands such as "put the
ball in the box"?
2 to 5 years
Yes
No
Yes
Yes
No
Listen to TV or radio at same loudness level
Point to a picture if you say "Where's the …"?
as other family members?
Hear you when you call child's name from
Talk in short sentences?
another room?
Notice most sounds?
(*Cononical babbling is defined as nonemphative babbling using several consonant and vowel combinations, such as
"itika", "dabata," "omada." It is quite different from common babbling, such as "dada," "mama," or "baba.")
C:\Documents\Pediatric Associates\Marketing\Website\Forms\EXCEL VERSION\3 Year Check-up
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Education