APD Questionaire Auditory Processing Program "*" indicates required fields Name*DOB* MM slash DD slash YYYY Age*Location for which you are filling the formChoose LocationCalgaryHigh RiverGrande PrairieParents / Guardians*Physician*School*Teacher*Person Completing Checklist*Please place a checkmark before each item that applies to the person being assessed: Has a history of hearing loss Has a history of ear infections Does not pay attention (listen) to instruction 50% or more of the time Does not listen carefully to directions-often necessary to repeat instructions Says “huh” and “what” at least five or more times per day Cannot attend to auditory stimuli for more than a few seconds Has a short attention span - If this item is checked, check appropriate time frame: Has a short attention span appropriate time frame: 0-2 minutes 5-15 minutes 2-5 minutes 15-30 minutes Please place a checkmark before each item that applies to the person being assessed: Daydreams, attention drifts, not with it at times. Is easily distracted by background sound(s) Has difficulty with phonics (knowing the sound of a written letter: example: “ssssss” sound = the letter “s”) Experiences problems with sound discrimination Forgets what is said in a few minutes Does not remember simple routine things from day to day Displays problems recalling what was heard last week, month, year Has difficulty recalling a sequence that has been heard Experiences difficulty following auditory directions Frequently misunderstands what is said Does not comprehend many words – verbal concepts for age/grade level Learns poorly through the auditory channel Has a language problem (morphology, syntax, vocabulary, phonology) Has an articulation (speech) problem Cannot always relate what is heard to what is seen Lacks motivation to learn Displays slow or delayed response to verbal stimuli Demonstrates below average performance in one or more academic areas Sensitivity to sound Loud environments Specific sounds (i.e., chewing, sniffing, nail clipping) Other Sensitivity to sound Other DetailsDiagnosis (or suspected diagnosis) Attention-Deficit/Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) Behavioural disorder Learning disorder Speech-language disorder Anxiety Other Behavioural disorder DetailsLearning disorder DetailsSpeech-language disorder DetailsAnxiety DetailsOther DetailsClassroom accommodationsCurrently working with SLP OT Psychologist/counsellor Additional commentsDate MM slash DD slash YYYY
