Listening Checklist
Name of Child
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Completed by: Parent / Carer / Teacher
Today's Date
-
Day
-
Month
Year
Date
1. History of ear infections / glue ear / or hearing problems? (add comments)
Yes
No
Comments
2. Difficulty coping with background noise?
Yes
No
Comments
3. Difficulty remembering spoken information or instructions?
Yes
No
Comments
4. Slow to respond to spoken questions or information?
Yes
No
Comments
5. Oversensitive to/dislike of loud or particular sounds?
Yes
No
Comments
6. Mishears words?
Yes
No
Comments
7. Intonation flat or monotonous? Poor at singing a tune?
Yes
No
Comments
8. Delay in developing clear speech or in using sentences?
Yes
No
Comments
9. Speech Therapy?
Yes
No
Comments
10. Difficulties in school?
Yes
No
Comments
How do your child's listening difficulties affect them at home?
How do your child's listening difficulties affect them at school?
I give consent for this form to be used in an audit of children receiving auditory stimulation / training on the understanding that my child will not be identified beyond his / her date of birth:
Yes
No
Your Name
First Name
Last Name
Submit
Should be Empty: