Early Head Start Sensory Screening Parent Interview
Child Name: ______Birth date: ______
Vision: Directions: Circle Yes or No for the current year
Age at Initial: ______Age at Year 2: _____ Age at Year 3: _____
Initial Date: ______Year 2 Date: ______Year 3 Date: ______
Initial / Year 2 / Year 31. Has your child ever had a vision check by a doctor or specialist? If yes, When? ______Name:______Results:______Date:____ / Y N
______
Yes answers for ANY item 1-12 indicates a need for discussion and follow up. / Initial / Year 2 / Year 3
1. Eyes crossed – turning in or out- at any time, or eyes that do not appear straight, especially when child is tired. / Y N / Y N / Y N
2. Has reddened eyes or eyelids / Y N / Y N / Y N
3. Has encrusted eyelids / Y N / Y N / Y N
4. Has frequent sties (pimple on eyelid) / Y N / Y N / Y N
5. Eyes appear to move more than other people’s eyes do? / Y N / Y N / Y N
6. Eyelids droop / Y N / Y N / Y N
7. Has white spots or cloudiness covering some or all of the center of the eye. / Y N / Y N / Y N
8. Complains of burning, itching or pain in eyes. / Y N / Y N / Y N
9. Stares at bright lights frequently or repeatedly flicks objects in front of face. / Y N / Y N / Y N
10. Is bothered by light more than you are. / Y N / Y N / Y N
11. The pupil, dark center of the eye, seems larger or smaller than other children’s eyes. / Y N / Y N / Y N
12. Complains of headache or nausea / Y N / Y N / Y N
YES answer for 3 or more on 13-25 indicates need for discussion and follow up. / Initial / Year2 / Year 3
13. Has watery eyes / Y N / Y N / Y N
14. Complains of tired eyes, rubs eyes often. / Y N / Y N / Y N
15. Moves head forward or backward while looking at distant objects. / Y N / Y N / Y N
16. Turns the head to use one eye only (closes or covers one year / Y N / Y N / Y N
17. Tilts the head to one side often, or all the time. / Y N / Y N / Y N
18. Places an object close to the eyes to look at it. / Y N / Y N / Y N
19. Squints while looking at objects. / Y N / Y N / Y N
20. Blinks more than you do. / Y N / Y N / Y N
21. Has difficulty walking or running; trips over objects more often than others do. / Y N / Y N / Y N
22. Unable to see distant objects. / Y N / Y N / Y N
23. Seems to see better during the day than at night / Y N / Y N / Y N
24. Is unable to stack blocks or other objects. / Y N / Y N / Y N
25. There is a history of lazy eye or vision problems in the family. / Y N / Y N / Y N
Vision Screening: To be completed by screener. Place a “P” for present or an “A” for absent
Year 1Right Left / Year 2
Right Left / Year 3
Right Left
Pupillary Response / ______ / ______ / ______
Corneal Light Reflex / ______ / ______ / ______
Cover – Uncover / ______ / ______ / ______
Tracking / ______ / ______ / ______
Blink Reflex / ______ / ______ / ______
Decisions Made/Actions Taken/Referrals and Follow Up: ______
______
HEARING
Age at Initial: ______Age at Year 2: ______Age at Year 3: _____
Initial Date: ______Year2 Date: _____ Year 3 Date: ______
Initial / Year 2 / Year 31. Has your child had ear infections?
If yes, how many times per year? / Y N
______ / Y N
______ / Y N
_____
2. Did your child have a newborn hearing at the hospital?
If yes, what were the results? ______/ Y N
3. Has your child had a hearing evaluation by an audiologist? If yes, When?
Results: _____Name: Date: ______/ Y N / Y N / Y N
Directions: Ask parent(s) to answer questions 1-8 for children UNDER 2 YEARS of ageand questions 6-12 for children 2 years and OLDER. A NO answer for items 1-7 or a YES answer for items 8-12 indicates the need for discussion and follow up.
Initial / Year 2 / Year 31. Reacts to sudden loud noises / Y N / Y N / Y N
2. Child turns head toward interesting sounds or when child’s name is called / Y N / Y N / Y N
3. Coos to him/her self and makes noises when he/she is alone / Y N / Y N / Y N
4. Uses his voice to get attention / Y N / Y N / Y N
5. Tries to imitate you if you- make his/her own sounds. / Y N / Y N / Y N
6. Seems to hear you if you talk in a whisper. / Y N / Y N / Y N
7. Seems to speak as well as other children the same age. / Y N / Y N / Y N
8. There is a history of hearing problems in the family / Y N / Y N / Y N
9. Seems to have difficulty hearing / Y N / Y N / Y N
10. Turns up television louder than other members of the family. / Y N / Y N / Y N
11. Seems to favor one ear over the other. / Y N / Y N / Y N
12. Makes you talk loudly or repeat frequently. / Y N / Y N / Y N
OAE Screening: To be completed by screener. Indicate P for Pass, R for Refer
Initial / Year 1 / Year 2 / Year 3Attach OAE form / Right / Left / Right / Left / Right / Left / Right / Left
Record Score
Decisions made/Actions taken including referrals and follow up with health providers: ______
Initial Screening
______
Staff SignatureDate
Annual Screening
______
Staff SignatureDate
______
Staff SignatureDate