Auditory Processing Disorder Questionnaire

ONLINE ARCHES APD Screening Questionnaire

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

MonthDayYear
Date
My Name:
My 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):
Special help with reading?

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

YESNoOther
DEC: 2. I have a problem understanding language

YESNoOther
DEC: 3. I have a problem understanding spoken instructions

YESNoOther
DEC: 4. I have a problem reading aloud

YESNoOther
DEC: 5. I have a problem with phonics (speech sounds)

YESNoOther
DEC: 6. I have a problem with spelling

YESNoOther
DEC: 7. I respond slowly/delayed to spoken language

YESNoOther
DEC: 8. I may have a problem learning a foreign language

YESNoOther
DEC: 9. I speak slowly

YESNoOther
NOISE
NOI: 1. I am hypersensitive to noise

YESNoOther
NOI: 2. I am distracted by noise

YESNoOther
NOI: 3. I struggle to understand speech in noise

YESNoOther
NOI: 4. I am noisy/makes more noises in comparison to their peers

YESNoOther
MEMORY
MEM: 1.I respond too quickly, at times

YESNoOther
MEM: 2. I interrupt frequently others talking

YESNoOther
MEM: 3. I have a problem with reading comprehension

YESNoOther
MEM: 4. I speak quickly

YESNoOther
MEM: 5. I forget things they have been told

YESNoOther
MEM: 6. I have a problem remembering spoken instructions

YESNoOther
VARIANCE
VAR: 1. I have a problem paying attention

YESNoOther
VAR: 2. I have a problem using language

YESNoOther
VAR: 3. I may have ADHD/ADD

YESNoOther
VAR: 4. I have anxiety (e.g., new situations)

YESNoOther
INTEGRATION
INT: 1. I have extremely poor handwriting

YESNoOther
INT: 2. I have a problem integrating auditory and visual info

YESNoOther
INT: 3. I have significant reading/spelling difficulties

YESNoOther
INT: 4. I may have significant visual perception difficulties

YESNoOther
INT: 5. I sometimes has very long response delays

YESNoOther
INT: 6. I have Dyslexia

YESNoOther
ORGANISATION
ORG: 1. I have a problem keeping things in organised

YESNoOther
ORG: 2. I have a problem sequencing verbal items/information

YESNoOther
ORG: 3. I am messy/tends to lose things

YESNoOther
APD/OTHER HISTORY
APD: 1. I have a history of ear infections / ear fluid as a child

YESNoOther
APD: 2. I have a problem understanding what is said

YESNoOther
APD: 3. I have a learning disability

YESNoOther
APD: 4. I have a problem following spoken instructions

YESNoOther
APD: 5. I have an intellectual disability

YESNoOther
APD: 6. I have had a head injury

YESNoOther
APD: 7. I have Autism or a related problem

YESNoOther
GENERAL CHARACTERISTICS
GEN: 1. I am hypersensitive to touch

YESNoOther
GEN: 2. I have a problem maintaining eye contact with a speaker

YESNoOther
GEN: 3. I have a problem with long-term memory

YESNoOther
GEN: 4. may have a psychological problem

YESNoOther
GEN: 5. I may have a behaviour problem

YESNoOther
GEN: 6. I may have a problem coordinating body movements

YESNoOther
GEN: 7. I may have allergies

YESNoOther
GEN: 8. I have a problem learning math concepts

YESNoOther
GEN: 9. I have a hearing problem

YESNoOther
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 HISTORY

GENERAL CHARACTERISTICS