Auditory Processing Assessment
Speech Pathology and Audiology
Flinders University, Adelaide
GPO Box 2100
Adelaide SA 5001
Tel: 08 8204 5942
Fax: 08 8204 5935
http://www.flinders.edu.au/speechpath/
CRICOS Provider No. 00114A
Auditory Processing Assessment
PARENT QUESTIONNAIRE
Child’s name: ………………………………………………………DOB: ……………………. Age: …….….
Address: ……………………………………………………………………………………………………....………
Email address: ………………………………………………………………………………………………..………..……
Phone: Home: ………………….………. Mobile: ……………………………… Work: …….…………...…..
School: ……………………………………………………………………..………………………………..………
Class Teacher: ……………………………………………….
Source and Reason for referral: ………………………………………………….……………………………..……….
………………………………………………………………………………………………………………….…………………
…………………………………………………………………………………………………………………………………….
Person(s) completing this questionnaire: ………………………………………………….. Date: …………………..
Background information
1. / Please indicate if your child has a history of any of the following (IF YES PLEASE DESCRIBE) :-physical/motor skills problems
speech/language problems
reading problems
middle ear infections
has your child had grommets (ear surgery)
hearing problems
sleeping problems / Y / N ......
Y / N ……………………………………………………..
Y / N ……………………………………………………..
Y / N ……………………………………………………..
Y / N ……………………………………………………..
Y / N ……………………………………………………..
Y / N ……………………………………………………..
2. / Has your child seen a speech pathologist? / Y / N ………………………………………………………
…………………………………………………………….
3. / Has your child seen a psychologist? / Y / N ………………………………………………………
…………………………………………………………….
4. / Does your child have any history of significant childhood illnesses or accidents? / Y / N …………..…………………………………………
……………………………………………………………
5. / Does your child have a diagnosed medical condition? / Y / N ………………………………………………………
…………………………………………………………….
6. / How is your child’s current health? / ……………………………………………………………..
…………………………………………………………….
7. / Is your child left or right handed or mixed? / L / R / M
8. / Has any family member had speech/language problems and/or learning difficulties?
(please state the nature of the problem and the relationship of the person to your child) / Y / N ……………………………………………………….
……………………………………………………………..
………………………………………………………………
Listening
1. / Is your child easily distracted by noise, e.g. television, talking / Y / N2. / Does your child have difficulty paying attention?
How do you notice this? ………………………………………………………………………
…………………………………………………………………………………………………… / Y / N
3. / Does your child avoid listening/talking activities?
How do you notice this? ………………………………………………………………………
…………………………………………………………………………………………………… / Y / N
4. / Does your child communicate more easily at certain times or in certain places at home? Please describe………………………………………………………………………..
…………………………………………………………………………………………………… / Y / N
Understanding speech/language
1. / Does your child …have difficulty following directions/instructions
ask for questions/instructions to be repeated
confuse similar words, e.g. pat/bat
follow the storyline when you tell him/her something
perform better when shown what to do rather than being told
understand better when spoken to individually
realise when s/he is not understanding someone/something
have difficulty understanding jokes / Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
2. / Do you find yourself slowing down your rate of speech when talking to your child in order to assist with his/her understanding? / Y / N
3. / Do you find yourself making certain your child is looking at you before you speak? / Y / N
4. / Does your child …
have a short attention span
day dream, appear “not with it” at times
forget what is said in a few minutes / Y / N
Y / N
Y / N
Behaviour
1. / Please indicate if any of the following describe your child …disorganised
has difficulty completing tasks
forgetful (generally)
forgets homework instructions
always on the go
is successful in relating to peers
anxious
talks excessively
fidgets/squirms
acts before thinking
clumsy
often tired / lethargic
dislikes / avoids noise
enjoys listening to music / Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Y / N
Learning skills
1.2. / Does your child often reverse letters/words in … reading
writing
Does your child like books / reading / Y / N
Y / N
Y / N
Speech
1. / Please indicate if any of the following apply to your child when s/he is answering questions or following instructions …responds appropriately
responds inconsistently
responds slowly / Y / N
Y / N
Y / N
2. / Please indicate if any of the following apply to your child when is telling a story or describing something:
confuses the order of events
lacks detail
says it in a way that you can understand
repeats him/herself
is keen to share his/her experiences with you / Y / N
Y / N
Y / N
Y / N
Y / N
Educational information
Rating ScaleBelow Avg. / Average / Above
Avg.
1 / 2 / 3 / 4 / 5
Please rate how your child performs in the following subjects …
reading
maths
spelling
writing i.e. written expression
art
music
sport / 1
1
1
1
1
1
1 / 2
2
2
2
2
2
2 / 3
3
3
3
3
3
3 / 4
4
4
4
4
4
4 / 5
5
5
5
5
5
5
Musical experience
1.2.
3. / Does your family listen to or play music at home?
How often? (please circle):
Occasionally / 1 or 2 days a week / most days of the week
Please describe……………………………………………………………………………………
………………………………………………………………………………………………………………………………
Does your child have music as a class lesson at school?
Please describe (e.g. how often do these lessons occur?) ……………………………….
……………………………………………………………………………………………………
Does your child have private music lessons?
Please circle: An Instrument / Voice / Both instrument and voice
How long has your child had music lessons for? ……………………………………………….. / Y / N
Y / N
Y / N
General information.
1. / What does your child do best?2. / What concerns you most about your child?
3. / Do you think your child performs to his/her best ability at school? / Y / N
4. / Do you think your child has concerns about him/herself?
Please explain:
5. / Would you be interested to be contacted about participating in scientific research? / Y / N
Thank you very much.