Developmental Screening for Hearing Impairment
Child's Name
Date of Birth
Sex
Male
Female
Date of Screening
Screened by
Medical History
Family history of hearing loss
Yes
No
History of neonatal intensive care
Yes
No
History of meningitis or severe infections
Yes
No
Other relevant medical history
Developmental Milestones
Responds to loud sounds (age in months)
Turns head towards sounds (age in months)
Babbles or uses voice (age in months)
First words (age in months)
Screening Observations
Behavioral observations
Parental concerns
Screening method used
Screening result
Pass
Refer
Comments / Recommendations