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To return to the Screening Forms Menu please use the "x" on the upper right hand side of this window.
Date: _______________________________________
Name of Child: ______________________________
Birth Date: __________________________________
Completed by: _______________________________
The information you provide on this form will be used by the school in vision screening of your child. Please complete it to the best of your knowledge and return it to the school.
1. Are there any known blood relatives in the family (parents, brothers, sisters, cousins, etc.) who have a hearing loss? If yes, please describe their hearing loss and cause, if known.
2. Are there any known cases of blood relatives who have trouble seeing at night? If yes, please explain.
3. Does your child have a congenital (existing from birth) hearing loss? If yes, please explain.
4. What is the cause of your child's hearing loss?
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