6. When sound is present or someone is speaking, does your child search to find where the sound is coming
from? YES NO
7. Does your child respond to sounds from other rooms?
8. Does your child enjoy listening to music? YES NO
9. Has your child’s hearing ever been tested? YES NO
If yes, please list by whom, when and results
10. Does your child wear hearing aid(s)? YES NO
If yes, when was your child first fit?
11. Does your ch
Pregnancy And Birth History (please check YES or NO)
1. Was the pre
gnancy abnormal in any way? YES NO
2. Was the delivery abnormal in any way? YES NO
3. Was the delivery premature? YES NO
4. Did the mother have any illness during the pregnancy? YES NO
5. Did the mother take any medication during the pregnancy? YES NO
6. After birth, did your child have:
Any head, neck or ear abnormalities?
Any infections requiring medication?
Treatment for jaundice (yellow coloration of the skin)?
If yes to any of the above, briefly explain: