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FUNCTIONAL HEARING CHECKLIST Name______________________________DOB_______________Date____________ Examiner_________________________ Pass_______________ Fail_______________ |
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| Yes | No |
Comments |
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| General Observation: redness, wax, draining. Does child pull, scratch, hold, or cover ears? | |||
| Does the child appear to have a problem hearing; does not respond to sounds? | |||
| Does the child appear to have difficulty reacting to sounds (i.e., turning to sound)? | |||
| Does the child appear to have difficulty discriminating (reacting differently to loud/soft, pleasant/unpleasant sounds)? | |||
| Does the child demonstrate difficulty recognizing familiar voices (does not react to a familiar voice)? | |||
| Does the child demonstrate no reaction/response to music? | |||
| Does the child appear to tune out at times (responds to sounds and other times no response to same sound)? | |||
| Does child appear to react to sound vibration rather than sound itself? | |||
| Does the child have a history of any of the following: family member w/hearing loss, malformations of the head/neck traumatic head injury, meningitis, congenital or perinatal infection? | |||
| *yes on two or more questions
constitutes a "fail" |
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hearcklst 7/2000