Appendix 2.3.4 - Kindergarten Hearing Checklist

Appendix 2.3.4
Kindergarten Hearing Checklist
(To be completed by Parent)
To the Teacher: If there are concerns regarding a child’s hearing, please send this home for a parent to
fill out. Most children will exhibit some of these symptoms occasionally. If a child exhibits more than one
of these symptoms routinely, parents should contact their physician.
Student:
School:
D.O.B.:
JK:
 SK:
Entry Date
Name of Person Completing This Form
Relationship to Student:

Date Completed:
Physical Signs:
___ Frequent upper respiratory problems – colds, sore throats, tonsillitis, mouth breathing
___ Complaints of noise, ear aches, stuffiness, dullness or ringing in the ear
___ Moisture or discharge in ear canal, odour from ears
___ Deformity or swelling on or about the ears
___ Poor balance or co-ordination
___ Rubbing or pulling at ears

Behaviours:
___ Holds head in peculiar position when spoken to (i.e. turns one ear to speaker)
___ Watches the speaker’s face, particularly the lips
___ Inability to locate the direction from which the sound comes; may fail to respond to sounds
___ Inability to hear conversation, especially in a group; may strain to listen, frown, squint, lean forward
___ Frequently misunderstands directions, even though attending to speaker
___ Frequently requests repetition of work, questions, instructions or assignments. Frequent use of
“What?”
___ Frequently fails to respond to questions or responds slowly
___ Signs of fatigue in the day
___ Repeatedly sits with blank expression; consistently seems inattentive or withdrawn
___ Turning television or radio up louder than comfortable for normal listening
___ Shows a marked change in responding following an illness, particularly a high fever disease
___ Inability to discriminate between words that sound alike
___ Omission of word endings, especially “s”
Do you have any concerns about your child’s hearing?
Yes ___ No ___
If yes, please explain:
Parents, please return completed form to school.
Parent/Guardian Signature:
Date: ______________________

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