Auditory Processing Disorder Questionnaire

ONLINE ARCHES APD Screening Questionnaire

Adapted from Buffalo Model Questionnaire - Revised Simplified Child Form
Today's date:

MonthDayYear
Date
Child's Name:
Child's Age:
Filled in by:
Please indicate if you are currently receiving or have received any of the services and number of years:
Auditory training?

YESNo
Details including type of services received and duration (months or years):
Speech Therapy?

YESNo
Details including type of services received and duration (months or years):
Phonological awareness training?

YESNo
Details including type of services received and duration (months or years):
Special phonics training?

YESNo
Details including type of services received and duration (months or years):
Special help with reading?

YESNo
Details including type of services received and duration (months or years):
Sensory-intergation training?

YESNo
Details including type of services received and duration (months or years):
Please mark 'YES' if the statement applies to you or "NO" if it not a problem.
DECODING
DEC: 1. My child has a problem saying speech sounds

YESNoMaybeOther
DEC: 2. My child has a problem understanding language

YESNoMaybeOther
DEC: 3. My child has a problem understanding spoken instructions

YESNoMaybeOther
DEC: 4. My child has a problem reading aloud

YESNoMaybeOther
DEC: 5. My child has a problem with phonics (speech sounds)

YESNoMaybeOther
DEC: 6. My child has a problem with spelling

YESNoMaybeOther
DEC: 7. My child responds slowly/delayed to spoken language

YESNoMaybeOther
DEC: 8. My child has a problem learning a foreign language

YESNoMaybeOther
DEC: 9. My child speaks slowly

YESNoMaybeOther
NOISE
NOI: 1. My child is hypersensitive to noise

YESNoMaybeOther
NOI: 2. My child is distracted by noise

YESNoMaybeOther
NOI: 3. My child struggles to understand speech in noise

YESNoMaybeOther
NOI: 4. My child is noisy/makes more noises in comparison to their peers

YESNoMaybeOther
MEMORY
MEM: 1. My child responds quickly, at times

YESNoMaybeOther
MEM: 2. My child frequently interrupts others talking

YESNoMaybeOther
MEM: 3. My child has a problem with reading comprehension

YESNoMaybeOther
MEM: 4. My child speaks quickly

YESNoMaybeOther
MEM: 5. My child forgets things they have been told

YESNoMaybeOther
MEM: 6. My child has a problem remembering spoken instructions

YESNoMaybeOther
VARIANCE
VAR: 1. My child has a problem paying attention

YESNoMaybeOther
VAR: 2. My child has a problem using language

YESNoMaybeOther
VAR: 3. My child has ADHD/ADD

YESNoMaybeOther
VAR: 4. My child has anxiety (e.g., new situations)

YesNoMaybeOther
INTEGRATION
INT: 1. My child has extremely poor handwriting

YesNoMaybeOther
INT: 2. My child has a problem integrating auditory and visual info

YesNoMaybeOther
INT: 3. My child has significant reading/spelling difficulties

YesNoMaybeOther
INT: 4. My child has significant visual perception difficulties

YesNoMaybeOther
INT: 5. My child sometimes has very long response delays

YesNoMaybeOther
INT: 6. My child has Dyslexia

YesNoMaybeOther
ORGANISATION
ORG: 1. My child has a problem keeping things in organised

YESNoMaybeOther
ORG: 2. My child has a problem sequencing verbal items/information

YESNoMaybeOther
ORG: 3. My child is messy/tends to lose things

YESNoMaybeOther
APD / OTHER SIGNIFICANT HISTORY
AUD: 1. My child has a history of ear infections / ear fluid as a child

YESNoMaybeOther
AUD: 2. My child has a problem understanding what is said

YESNoMaybeOther
AUD: 3. My child has a learning disability

YESNoMaybeOther
AUD: 4. My child has a problem following spoken instructions

YESNoMaybeOther
AUD: 5. My child has an intellectual disability

YESNoMaybeOther
AUD: 6. My child has had a head injury

YESNoMaybeOther
AUD: 7. My child has Autism or a related problem

YESNoMaybeOther
GENERAL CHARACTERISITICS
GEN: 1. My child is hypersensitive to touch

YESNoMaybeOther
GEN: 2. My child has a problem maintaining eye contact with a speaker

YESNoMaybeOther
GEN: 3. My child has a problem with long-term memory

YESNoMaybeOther
GEN: 4. My child has a psychological problem

YESNoMaybeOther
GEN: 5. My child has a behaviour problem

YESNoMaybeOther
GEN: 6. My child has a problem coordinating body movements

YESNoMaybeOther
GEN: 7. My child may have allergies

YESNoMaybeOther
GEN: 8. My child has a problem learning math concepts

YESNoMaybeOther
GEN: 9. My child has a hearing problem

YESNoMaybeOther
Would you like to add any other information?
Would you like to be contacted about these results?

YESNoOther
Please enter your best contact details (phone call/sms/email)
Thank you for your interest in APD services at Arches Audiology.

For more information, please visit www.archesaudiology.com.au.

We welcome all enquiries: contact@archesaudiology.co m.au or 0423 374 684.
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ONLINE ARCHES APD Screening Questionnaire

DECODING

NOISE

MEMORY

VARIANCE

INTEGRATION

ORGANISATION

APD / OTHER SIGNIFICANT HISTORY

GENERAL CHARACTERISITICS