Community Care & Health Department

Community Care & Health Department

HEARING CHECKLIST

Name
DOB / PCAS NO:
Address
Completed by & Date
Please indicate by Ö
Or comment / Yes / Sometimes/
Don’t know / No / Comments

SPEECH

1. Speaks very loudly or quietly
2. Speaks in a monotonous voice/tone
3. Speech which others find hard to understand

NON VERBAL

4. vocalises very loudly.

APPEARANCE

5. Unusual appearance of ears.
6. Discharging ears/ears with an unpleasant smell

BEHAVIOUR

7. Frequent touching of ears, e.g. poking, rubbing, head-slapping.
8. Sticks objects or fingers into ears.
9. Unusual head movements, e.g. turns head to one side to hear.
10. Cups hand behind ear to amplify sound.
11. Breathes through mouth and not nose, gets a blocked up nose.
12. Problems with balance.
CHANGES IN BEHAVIOUR
13. Dramatic recent changes in behaviour.
14. Seems confused
15. Increasing lack of co-operation in person previously co-operative
Name
DOB / PCAS NO:
Please indicate by Ö
Or comment / Yes / Sometimes/
Don’t know / No / Comments
RESPONSE TO OTHER PEOPLE
16. Startled by people coming up close or touching them from behind.
17. Does not respond when called by name
18. Does not respond to verbal instructions
19. Watches peoples faces very closely.
20. Ignores people who are not within sight.
21. Appears to hear deep/high pitched voices best.

UNDERSTANDING

22. Needs a visual prompt e.g. seeing a cup when offered a drink.
23. Takes time to tune in and understand what is being said.
24. Has difficulty coping with a change in topic of conversation.
25. Misses part of conversation.
26. Understands people best who have expressive faces/body language.
RESPONSES TO THE ENVIRONMENT
27. Needs to sit very close to the TV or music, or have it turned up loud.
28. Flinches or seems distressed by loud noises.
29. Does not recognise certain sounds.

C: Louise McMillan, Speech & Language Therapist 01454 862461 August 2006