theme of justice to king lear
Listening Skills Questionnaire
Date: ____________ Client:
Age:
Filled-Out By: _____________________
Relationship / Title:
Developmental and Environmental History (Please check if applicable)
History of ear infections
Delayed motor development
Delayed speech or language development Emotional trauma, including dangerous or frightening experiences
Exposure to loud sounds such as gunfire or loud concerts
Ringing in one or both ears
(which?_______________)
Concussion or head trauma
Headaches
This questionnaire is designed to provide information about the client’s auditory processing skills and the effect that they are having on language, communication, behavior, learning, and motor skills.
Please respond to each of the following based on how this individual compares with others of similar age and background.
Response Choices
0:
1:
2:
3:
4:
Not a problem
Seldom
Sometimes
Often
Very often
Ability to Understand What Other People Say
0
1
2
3
4
0
1
2
3
4
Needs to have information or instructions repeated
Says, “Huh?” or “What?”
Confuses similar sounding words
Has difficulty understanding discussions
Has difficulty following conversations
Has difficulty remembering / following more than one or two directions
Has trouble understanding humor / jokes
Listening Skills and Conditions; Auditory Memory
Easily distractible when listening
Short auditory attention span
Oversensitive to certain sounds
Tires easily
1
15192 Central Ave., Chino, CA 91710
(909) 598-2482
www.learningdisability.com
Becomes sleepy when listening to speakers
Feels that people talk too fast
Gets confused in noisy situations
Trouble with sound discrimination (phonemic awareness) Daydreams or tunes out in class
Difficulty hearing and understanding in background noise such as TV, others talking, music, children playing, etc.
Difficulty hearing and understanding in a quiet room
(others
Date: ____________ Client:
Age:
Filled-Out By: _____________________
Relationship / Title:
Developmental and Environmental History (Please check if applicable)
History of ear infections
Delayed motor development
Delayed speech or language development Emotional trauma, including dangerous or frightening experiences
Exposure to loud sounds such as gunfire or loud concerts
Ringing in one or both ears
(which?_______________)
Concussion or head trauma
Headaches
This questionnaire is designed to provide information about the client’s auditory processing skills and the effect that they are having on language, communication, behavior, learning, and motor skills.
Please respond to each of the following based on how this individual compares with others of similar age and background.
Response Choices
0:
1:
2:
3:
4:
Not a problem
Seldom
Sometimes
Often
Very often
Ability to Understand What Other People Say
0
1
2
3
4
0
1
2
3
4
Needs to have information or instructions repeated
Says, “Huh?” or “What?”
Confuses similar sounding words
Has difficulty understanding discussions
Has difficulty following conversations
Has difficulty remembering / following more than one or two directions
Has trouble understanding humor / jokes
Listening Skills and Conditions; Auditory Memory
Easily distractible when listening
Short auditory attention span
Oversensitive to certain sounds
Tires easily
1
15192 Central Ave., Chino, CA 91710
(909) 598-2482
www.learningdisability.com
Becomes sleepy when listening to speakers
Feels that people talk too fast
Gets confused in noisy situations
Trouble with sound discrimination (phonemic awareness) Daydreams or tunes out in class
Difficulty hearing and understanding in background noise such as TV, others talking, music, children playing, etc.
Difficulty hearing and understanding in a quiet room
(others