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