Vision And Hearing Screen

Students name: ______________________________________

Date of Birth: __________________________________
Initial Screen Vision
Has glasses/contacts:

Grade/School:____________________

Re-screen Vision
Yes

No

Date_______

Has glasses/contacts:

Wearing glasses/contacts for screening:

Yes

Date of Screening:____________

Yes

No

Wearing glasses/contacts for screening:

No

Yes

No

Right Eye:_________________________

Right Eye:_________________________

Left Eye: __________________________

Left Eye: __________________________

Pass
__________

Pass
__________

Rescreen
__________ Acuity

Rescreen
__________ Acuity

10-foot Sloan Chart

10-foot Sloan Chart

Initial Screen Hearing

Hearing at 20 dB using 25-Maico Audiometer

Immed. Re-Screen Hearing

Hearing at 20 dB using 25-Maico Audiometer

Has cold or congestion?

Has cold or congestion?

Yes

No

Conditioning tone at 40dB @1000Hz

Yes

No

Conditioning tone at 40dB @1000Hz

dB level

25

20

20

20

dB level

25

20

20

20

Hz Freq.

500 Hz

1000 Hz

2000 Hz

4000 Hz

Hz Freq.

500 Hz

1000 Hz

2000 Hz

4000 Hz

Rt. Ear

Rt. Ear

Lt. Ear

Lt. Ear

= response
Results Summary (circle):

=no response

= response

Vision

Pass

Refer

Hearing

Pass

Refer

=no response

Comments: ______________________________________________________________________
Screener: _______________________________________________________________________
Referral letter sent to parent on: ______________________________________________________