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 / N
2. / 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 Scale
Below 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.