CHILD'S NAME_____________________AGE___DATE___EVALUATIOR___________

DATE AMPLIFICATION INTRODUCED_______DATE OF PRIOR EVALUATION_______
Hearing Behavior: Rate child's hearing behavior since amplification
was introduced (or since previous evaluation) as follows: (5)Marked
improvement, (4)Some improvement, (3) No improvement, (2)Some loss
of hearing skills, (1)Marked loss of hearing skills.

Locates environmental sounds excluding speech.      5__4__3__2__1__ 

Locates speech of person talking.                   5__4__3__2__1__

Discriminates gross environmental sounds.           5__4__3__2__1__

Discriminates sophisticated environmental sounds.   5__4__3__2__1__

Recognizes spoken vowels without visual cues.       5__4__3__2__1__

Recognizes diphthongs without visual cues.          5__4__3__2__1__

Recognizes low Hz consonants /m/,/z/,/d/ etc.       5__4__3__2__1__

Recognizes high Hz consonants /s/,/f/, /xh/ etc/    5__4__3__2__1__

Recognizes singing patterns.                        5__4__3__2__1__

Recognizes speech intonation patterns.              5__4__3__2__1__

Recognizes varying syllable stress patterns.        5__4__3__2__1__

Recognizes vocabulary words without cues.           5__4__3__2__1__

Recognizes oral sentences without cues.             5__4__3__2__1__

Auditory memory span with amplification.            5__4__3__2__1__

Wearable hearing aid? Yes__ No__ If "Yes," what type?_______________

Has hearing aid functioned appropriately and consistently?Yes__No__
    If "No," please explain problem._______________________________

Is wearable hearing aid the best possible form of amplification for 
    this child at this time? Please rate benefits:____Maximum use
    of aid; _____Aid of some benefit, _____Marginal and doubtful
    benefit, _____Of no value and should be abandoned.

Is child exposed to other forms of amplification? List:____________

Child's responses to other forms of amplification. Describe________
  ______________________________________________________________.

Is there evidence to suspect improved or deteriorated hearing? 
     Yes___ No____