Auditory Processing Disorder Questionnaire

BUFFALO MODEL QUESTIONNAIRE - REVISED

Simplified Adult Form
Today's date:

MonthDayYear
Date
My Name:
My Age:
My DOB:
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.
DEC
I have a problem saying speech sounds

YESNoOther
I have a problem understanding language

YESNoOther
I have a problem understanding spoken instructions

YESNoOther
I have a problem reading aloud

YESNoOther
I have a problem with phonics (speech sounds)

YESNoOther
I have a problem with spelling

YESNoOther
I respond slowly/delayed to spoken language

YESNoOther
I may have a problem learning a foreign language

YESNoOther
I speak slowly

YESNoOther
NOI
I am hypersensitive to noise

YESNoOther
I am distracted by noise

YESNoOther
I struggle to understand speech in noise

YESNoOther
I am noisy/makes more noises in comparison to their peers

YESNoOther
MEM
I respond too quickly, at times

YESNoOther
I interrupt frequently others talking

YESNoOther
I have a problem with reading comprehension

YESNoOther
I speak quickly

YESNoOther
I forget things they have been told

YESNoOther
I have a problem remembering spoken instructions

YESNoOther
VAR
I have a problem paying attention

YESNoOther
I have a problem using language

YESNoOther
I may have ADHD/ADD

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

YESNoOther
INT
I have extremely poor handwriting

YESNoOther
I have a problem integrating auditory and visual info

YESNoOther
I have significant reading/spelling difficulties

YESNoOther
I may have significant visual perception difficulties

YESNoOther
I sometimes has very long response delays

YESNoOther
I have Dyslexia

YESNoOther
ORG
I have a problem keeping things in organised

YESNoOther
I have a problem sequencing verbal items/information

YESNoOther
I am messy/tends to lose things

YESNoOther
APD
I have a history of ear infections / ear fluid as a child

YESNoOther
I have a problem understanding what is said

YESNoOther
I have a learning disability

YESNoOther
I have a problem following spoken instructions

YESNoOther
I have an intellectual disability

YESNoOther
I have had a head injury

YESNoOther
I have Autism or a related problem

YESNoOther
GEN
I am hypersensitive to touch

YESNoOther
I have a problem maintaining eye contact with a speaker

YESNoOther
I have a problem with long-term memory

YESNoOther
I may have a psychological problem

YESNoOther
I may have a behaviour problem

YESNoOther
I may have a problem coordinating body movements

YESNoOther
I may have allergies

YESNoOther
I have a problem learning math concepts

YESNoOther
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.
Should be Empty:

BUFFALO MODEL QUESTIONNAIRE - REVISED

DEC

NOI

MEM

VAR

INT

ORG

APD

GEN