This checklist is designed to help parents access whether their child/children might be having problems with their auditory system.
Check off any item that applies to your child. If you check off many items, read about Auditory Integration Training and consider scheduling an auditory assessment
Name.............................. Date of birth.................. Tel.................................. Date............................
1. History of middle ear infections 2. History of middle ear infections before three years 3. History of grommets operations (tubes) 4. Does not pay attention to instructions (teaching, listening)50% or more of the time 5. Has difficulty following spoken instructions 6. Often necessary to repeat instructions 7. Always need the TV on louder than everyone else 8. Slow processing of auditory input 9. Cannot always relate what is heard to what is seen 10. Frequently misunderstands what is said 11. Often asks for repetition of what was said 12. Says "huh" and/or what? 13. Forgets what was said in a few minutes 14. Has short attention span 15. Daydreams, attention drifts 16. Easily distracted by sound 17. Cannot attend to purely auditory input for more than a few minutes 18. Ability to work deteriorates in groups or crowds 19. Experiences problems with sound discrimination 20. Has problems with phonics 21. Finds it difficult to remember or repeat sequences 22. Is bothered by sounds/covers ears/painful reaction/discomfort 23. Notices sounds before others do 24. Is startled by sounds that don't bother anyone else 25. Needs loud music to be able to concentrate on homework 26. Seeks "quite time" 27. Does not comprehend many words/concepts for his/her age 28. Has a language problem (grammar, vocabulary, etc) 29. Has a articulation problem (speech) 30. Has a problem relating a story or event 31. Has a reading and /or spelling problem 32. Makes more mistakes at the beginning of a task than at the end 33. Makes more mistakes at the end of a task than at the beginning 34. Is disruptive or annoying behavior 35. Withdraws socially 36. Inconsistencies of performance and of errors 37. Appears to be underachieving scholastically 38. Gives unusual descriptions of sounds 39. Constant humming or audible self-talk 40. Is considered to have a learning disability, ADD, ADHD, CAPD, PDD, autism, Asperger's Syndrome, hypersensitive hearing, speech defect, stuttering. TOTAL =
THIS AUDITORY PROBLEMS CHECKLIST WAS COMPILED AS PART OF A RESEARCH PROJECT INTO AUDITORY PROCESSING PROBLEMS IN CHILDREN AND ADULTS, WITH REFERENCE TO THE FISCHER'S APC AND THE WORKS OF A.J. KATZ.
Thank you for your co-operation Khymberleigh D. Herwill-Levin (Auditory Integration Practitioner)
Parents name ....................................................
COPY, PASTE AND PRINT Then fill in the forms Send together with checklist to Head Office Khymberleigh Herwill-Levin Learning to Listen - THE BRAIN FITNESS CENTER P.O. Box 1557 Zephyr Cove NV, 89448
SERVICES ARE PAID FOR AT BEGINNING OF THE TRAINING
