Risk Indicators For Hearing Loss Checklist Form

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Revised 04.2016
Risk Indicators for Hearing Loss Checklist
(To be used with the Developmental Scales form when performing KBH screens for birth through four years of age.)
Child’s name: ______________________________________________ Birthdate: _______________
What was your child’s birth weight? ________ Premature? _________ By how many weeks? _______
Was the child’s hearing screened as a newborn? Yes ____
No ____ Unknown ____
Results of the testing/screening: ___________________________________________________
Has your child’s hearing been tested or screened since birth? Yes ____ No ____ Unknown ____
Results of the testing/screening: ___________________________________________________
Directions: Mark an X in the appropriate column. If an indicator exists but has been referred in a
previous screening, note to whom the child was referred and note the follow-up recommendations.
{N = indicator for infants birth through 28 days old who did not have newborn hearing screening; for children older than 28
days, answer all questions.}
YES
NO
____
____
1. Do you have a concern about your child’s hearing, speech, language or other development delay?
List concerns:___________________________________________________________________
____
____
2. N As a newborn, did your child have an illness/condition requiring 48 hours or more in the NICU?
Explain: _______________________________________________________________________
3. N Was your child exposed to any of the following during the mother’s pregnancy? Check all that apply:
____
____
toxoplasmosis
syphilis
rubella
cytomegalovirus
herpes
unknown
____
____
4. N Does your child have any abnormal features of the outer ear, ear canal, mouth, nose, neck
or head?
Explain: _______________________________________________________________________
____
____
5. N Have any of your child’s relatives had a permanent hearing loss before the age of 5?
Explain: _______________________________________________________________________
6. N Was your child diagnosed at birth as having a syndrome or condition known to include a sensorineural or
____
____
conductive hearing loss or eustachian tube dysfunction?
Explain: _______________________________________________________________________
____
____
7. Has your child been diagnosed as having any syndromes associated with progressive hearing loss such as
Down, Usher, Waardenburg; a neurodegenerative disorder such as Hunter syndrome; or sensory motor
neuropathies such as Friedreich’s ataxia or Charcot-Maire-Tooth Syndrome?
Explain: _______________________________________________________________________
____
____
8. Has your child had bacterial meningitis (or other postnatal infections) associated with hearing loss?
If yes, at what age? _________________ Hearing testing since then? ______________________
____
____
9. Has child ever had any head trauma?
Explain: _______________________________________________________________________
____
____
10. As a newborn, did your child need an exchange transfusion because of hyperbilirubinemia, or have the need
for mechanical ventilation, or conditions requiring ECMO?
Explain: _______________________________________________________________________
____
____
11. Has your child had otitis media with effusion that lasts for more than 3 months? Yes ___ No ___
If yes, were tubes placed? Yes ___ No ___ If yes, when? ___________ Are they in place now? Yes ___ No ___
Note: The presence of any risk indicator denotes need for screening every six months up to three years of age or as otherwise
indicated by an audiologist.
Pass = All “NO” responses. Refer = One or more “YES” response(s). Check One: Pass
Refer
If other, explain: _______________________________________________________________________________
Screener: ___________________________________________________ Date: __________________
PLEASE NOTE PROVIDERS ARE REQUIRED TO INTERPRET
AND INITIATE CARE WHEN INDICATED.
Excerpted from Hearing Screening Guidelines and Resource Manual (January 2004)

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