Download EHS Vision and Hearing Screening

EHS SKCDC Vision and Hearing Screening
Child’s Name:
Family Educator:
Birth date:
Initial Screening Date:
Vision: Child to be referred based on Appearance/Behavior/Comp ___Yes ___No
Screened for hearing loss at birth?
□ Unknown □ Not screened □ Passed □ Referred
Related to Seeing and Hearing in Young Children
SEEING: Does the Child…
Y
N
HEARING:
2 Months:
2 Months:
• Look at your face? (briefly
looking by 1 month old)
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
Can’t test
Refer
Pass
Can’t test
Refer
Pass
Can’t test
Refer
Pass
Can’t test
Refer
Pass
Can’t test
Refer
Pass
• Imitate your smile? (2 mo.)
4 & 6 Months Old:
4
6
4
6
• Smile at others?
• Look at own hands?
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
6 Months old:
• Reach out and bat at objects?
9 & 12 Months Old:
4 Months Old:
9 12 9 12
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST
OAE (____/____/____)
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
9 Months Old:
• Try to reach out and grasp at
toys or other objects? (6 mos.)
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
• Notice something small (Ex:
raisin) when 12 inches from
him? (6 mos.)
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
• Try to move toward an object
that is at least 5 feet away? (7
mos.)
12 Months Old:
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
• Pick up or attempt to pick up a
cheerio, raisin, or lint? (8 mos.)
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
• Imitate movements or actions
of another person on a toy? (9
mos.)
• Stare at or try to grab your
jewelry or glasses? (9 mos.)
Can’t test
• Look for dropped toy? (9 mos.)
15 Months Old:
• React to facial expressions of
others (Ex. frowns, smiles,
funny faces)? (10-12 mos.)
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
15 & 18 Months Old:
• Show an interest in picture
books? (12 mos.)
15 18 15 18
Refer
Pass
18 Months Old:
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
• Imitate scribbling? (8-15 mos.)
• Reach into a container and pull
objects out easily? (12-18 mos.)
Revised 01.15.2015
SEEING: Does the Child…
24 & 30 Months Old:
Y
N
24 30 24 30
HEARING:
24 Months Old:
Can’t test
• Imitate crayon stroke? (24-30
mos.)
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
• Copy circle made by another
person?
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
Color Identification:
30 Months Old:
• Match two items that are the
same color? (24-32 mos.)
LEFT Ear
1ST OAE (____/____/____)
RIGHT Ear
1ST OAE (____/____/____)
Object to Picture Matching and
Picture Identification:
LEFT Ear
2nd OAE (____/____/____)
RIGHT Ear
2nd OAE (____/____/____)
• Identify one picture of a
familiar item? (18-24 mos.)
Additionally @ 30 months
• Identify two or more pictures?
(24-32 mos.)
• Hear TV or radio at same loudness level as other family members?
• Match objects with pictures of
objects? (24-36 mos.)
• Notice sounds--dogs barking, phones ringing?
Does your child say …?
• Use 1-2 prepositions (in, on, under)?
"My eyes are itchy."
• Use plurals? (Ex: dogs, cookies)
"My eyes hurt."
• Refer to self using a pronoun (I, me)?
"Things look blurry."
• Use 200+ words? (300+ by age 3?)
Refer
Pass
Y
N
• Give full name when asked? by age 3
Referred to:
• Help tell stories? by age 3
____ PCP
• Ask questions beginning with "what," "where," or "when"? by age 3
____ Ophthalmologist ___________________________
• Use speech that can be understood by others most of the time?
____ Optometrist _______________________________
Date: __________________________
Referred to PCP: Date: __________________________
2
4
6
9
Months
12
15
18
24
30
Date
@ 30 months:
Date: _________________
Height: ________________
Initials
Weight: ________________
Within
Normal
Further
Assessment
V
H
V
H
Discussed
w/Parent
Follow up completed/date: ____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Revised 01.15.2015