Auditory Processing Assessment PARENT QUESTIONNAIRE

Auditory Processing Assessment PARENT QUESTIONNAIRE
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: …………………….
Address:
……………………………………………………………………………………………………....………
Email address:
………………………………………………………………………………………………..………..……
Phone: Home:
………………….……….
School:
……………………………………………………………………..………………………………..………
Class Teacher:
……………………………………………….
Mobile: ………………………………
Age: …….….
Work: …….…………...…..
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?
3.
Has your child seen a psychologist?
4.
Does your child have any history of significant
childhood illnesses or accidents?
5.
Does your child have a diagnosed medical
condition?
Y / N ………………………………………………………
…………………………………………………………….
Y / N ………………………………………………………
…………………………………………………………….
Y / N …………..…………………………………………
……………………………………………………………
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. Does your child often reverse letters/words in …
2.
Y/N
Y/N
Y/N
reading
writing
Does your child like books / reading
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
2.
Y/N
Y/N
Y/N
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
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
Please rate how your child performs in the following subjects …
reading
maths
spelling
writing i.e. written expression
art
music
sport
Musical experience
1. 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……………………………………………………………………………………
Y/N
………………………………………………………………………………………………………………………………
2.
Does your child have music as a class lesson at school?
Please describe (e.g. how often do these lessons occur?) ……………………………….
……………………………………………………………………………………………………
Y/N
3.
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
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?
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?
Thank you very much.
Y/N
Y/N
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

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