Developmental Scales Template
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2Revised 04.2016
Developmental Scales
(To be used with Risk Indicators for Hearing Loss Checklist when performing KBH screens for 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
No
Stir or awaken when sleeping quietly and
Cry when exposed to a sudden or loud
someone talks or makes a loud noise?
sound?
Try to turn head toward an interesting
Make several different babbling sounds?
sound or when name is called?
Listen to a soft musical toy, bell, or rattle?
8 to 12 months
Yes
No
Yes
No
Respond in some way to the direction “no”?
Stir or awaken when sleeping quietly and
someone talks or makes a loud sound?
React to name when called?
Try to imitate you if you make familiar
sounds?
Turn head toward the side where a sound
Use variety of different consonants and
is coming from?
vowels when babbling (cononical
babbling*)?
12 to 18 months
Yes
No
Yes
No
Say “mama” or “dada” and imitate many
Turn head to look in the direction where
words you say?
the sound came from when an interesting
sound is presented?
Respond to requests such as “come here”
Wake up when there is a loud sound?
and “do you want more”?
18 to 24 months
Yes
No
Yes
No
Try to sing?
Speak at least 20 words?
Point to several different body parts?
Request by name items such as milk or
cookies?
Respond to simple commands such as “put
the ball in the box”?
2 to 5 years
Yes
No
Yes
No
Point to a picture if you say “Where’s the
Listen to TV or radio at same loudness
_________”?
level as other family members?
Talk in short sentences?
Hear you when you call child’s name from
another room?
Notice most sounds?
(*Cononical babbling is defined as nonrepetitive 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.”)
Pass = All “YES” responses or only one “NO” response. Refer = Two or more “NO” responses.
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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