# Risk factor classification Yes No Unsure
1 Family history of early, progressive, or delayed onset permanent childhood hearing loss
2 Neonatal intensive care of more than 5 days
3 Hyperbilirubinemia
4 Aminoglycoside administration for more than 5 days
5 Asphyxia or Hypoxic Ischemic Encephalopathy
6 Extracorporeal membrane oxygenation (ECMO)
7 In utero infections, such as herpes, rubella, syphilis, and toxoplasmosis
8 Certain birth conditions or findings:
  • Craniofacial malformations including microtia/atresia, ear dysplasia, oral facial clefting, white forelock, and microphthalmia
  • Congenital microcephaly, congenital or acquired hydrocephalus
  • Temporal bone abnormalities
9 Syndrome: _____________________________________
Perinatal or Postnatal
10 Infections associated with sensorineural hearing loss, including meningitis or encephalitis
11 Events associated with hearing loss:
  • Significant head trauma especially basal skull/temporal bone fractures
12 Caregiver concern regarding hearing, speech, language, development delay and/or development regression
Emerging factors from LMICs
13 Maternal hypertensive disorders in pregnancy
14 Non-elective caesarean delivery
15 Unskilled attendant at delivery
16 Undernutrition
Possible risk-factor for the Pacific Islands
17 Gestational diabetes