<p> Welch-Schmidt Center for Communication Disorders University of Central Missouri, Warrensburg MO 64093, 660-543-4993</p><p>Audiologic Screening for Hearing Loss and External/Middle Ear Disorders School-Age Children</p><p>Client/Patient Name: Date: Examiner: </p><p>History: (R or L for right or left ear only, B = both ears) otalgia otorrhea ear infections difficulty hearing other: </p><p>Visual Inspection, including otoscopy: R or L for right or left ear only, B = both ears) Structural defect of ear, head, neck Explain: </p><p>Ear canal abnormalities: R or L for right or left ear only, B = both ears) blood effusion inflammation excessive cerumen foreign object other: </p><p>Ear drum abnormalities: inflamed bulging meniscus perforation PE tubes retraction tympanosclerosis other: </p><p>Hearing screen at 20 dB HL: 1000 Hz 2000 Hz 4000 Hz Right P = Pass (tone heard) Left NR= No response</p><p>Tympanometry: PV COMP MEP TW (Earscan Display) Canal Peak Peak Gradient Jerger Volume admittance Pressure (TW in Type (mmho) Ytm (mmho) (daPa) daPa) (A As Ad B C) Right Left Referral criteria: One year to school age (six years): Ytm < 0.3 mmho or TW > 200 daPa School age (> 6 years): Ytm < 0.4 mmho or TW > 200 daPa</p><p>Recommendations: Pass Refer Rescreen: Audiometry Tympanometry</p><p>Comments:</p><p>Screening form based on ASHA 1997 Guidelines. Introduction to Audiology student practical final exam, Fall 2012.</p>