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Parent Checklist

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 ....................................................

Parents signature................................................

Date..................................................................

 

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

CASH, CHECK AND CREDIT CARDS ARE WELCOME

 


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