Listening Questionnaire
Copyright: The Listening Centre, Toronto, Canada.
Email address *
Name of Child *
Your answer
Age *
Your answer
Date *
Your answer
Name of Parent *
Your answer
Address *
Your answer
Telephone Number *
Your answer
Section -1.1 Tends to put volume lower (audio devices, TV, etc) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 1.2. Is overly sensitive or irritated by certain sounds (complains that some voices/music "hurt" him/her) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 1.3. Is overly distracted by ambient noises. *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 1.4 - Tends to hum or make involuntary voice noises *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 1.5 - Easily overwhelmed by sound/verbal information- tends to "blank out" or yawn (information overload) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 1.6 - tends to hear unusually faint sounds *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.1 Needs instruction repeated *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.2 - Tends to put volume higher (audio devices, TV, etc) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.3 - Misinterprets what has been said *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.4 - Confuses similar sounding words *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.5 - Is inattentive when spoken to *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.6 Has difficulty remembering names *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.7 Fidgets especially when listening *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.8 Has difficulty following multiple instructions. *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.9 - Has short attention span in the classroom *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.10 - Has long delay time before responding to questions *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.11 - Has difficulty in remembering melodies *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 2.12 - performs better in a quiet environment *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 3.1 - In reading, has difficulty converting letters into sounds (decoding) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 3.2 - Reads Slowly *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 3.3 - Needs the support of an image to understand what he/she reads *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 3.4 - Tires easily when reading ("my eyes get tired") *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 3.5 - In math - good in calculus but has difficulty with word problems *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 3.6 - Views reading as a "boring" activity *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 4.1 - Has difficulty understanding math concepts *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 4.2 - Needs to underline with finger when reading *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 4.3 - Can read the words but poor comprehension *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 4.4 - Reverses letters/words when reading *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 4.5 - Reacts to reading with discomfort *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 4.6 - Has difficulty catching a ball *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.1 - Has difficulty with balance (i.e. learning to ride a bike or skate or roller blade) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.2 - Has poor posture *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.3 - Has difficulty seating still, tends to fidget *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.4 - Has low muscle tone *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.5 - Tends to stumble, trip, bump into things and/or to be accident prone *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.6 - Tends to misread non-verbal cues *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.7 - Confuses left and right *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.8 - Has a poor sense of direction *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.9 - Has difficulty following time schedules *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.10 - Tends to learn in "spurts" rather than in a continuous flow *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.11 - Has a craving for movement (trampoline, swings, pacing) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 5.12 - Has difficulty learning times table *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 6.1 - Fears or feels uncomfortable in darkness *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 6.2 - Feels uncomfortable in high places (fear of heights, fear of falling) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 6.3 - Tends to shy away from and/or be uncomfortable with physical contact *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 6.4 Has difficulty with busyness (crowded classroom, playground, shopping mall, etc) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 6.5 - Finds it difficult adjusting to a new environment or situation *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 6.6 - Is prone to motion sickness *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 7.1 - Tends to overreact, to be overly defensive or unpredictable (short temper, "thin skin") *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 7.2 - Tends to seek attention by winning, crying complaining *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 7.3 - Tends to shy away from physical activity (sports) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 7.4 - Is overly self-conscious in public *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 7.5 - Feels uncomfortable or fearful participating in group activities or sports *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 7.6 - "Freezes" or "blanks out" when asked to speed up (i.e. when under a time constraint) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.1 - Is uncoordinated in his/her movements (clumsy, awkward) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.2 - Has a poor sense of rhythm (ie has difficulty repeating rhythmic pattern or dancing) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.3 - Has difficulty getting organized *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.4 - Has difficulty staying on task *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.5 - Has difficulty planning a series of tasks to be carried out (sequencing) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.6 - Speaks with poor sentence structure *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.7 - Has poor gross motor skills (i.e. difficulty swimming, jumping, running) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.8 - Procrastinates ("all talk, no action") *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.9 - Is attracted by computer games and/or other activities which ask for attention to small details *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.10 - Has difficulty relating to the peer group (making friends) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.11 - Speech flow is choppy (hesitation, redundant speech, verbal ticks) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 8.12 - When talking, has difficulty maintaining coherent and consistent story line *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 9.1 - Confuses or reverses letters/numbers in writing *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 9.2 - In spelling, tends to write words as they sound (mistake/mistake, bol/ball, anchor/nature) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 9.3 - Has difficulty with eye-hand coordination in sports (throwing a ball) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 9.4 - Has messy handwriting *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 9.5 - When writing has difficulty with constructing sentences (grammar, syntax) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 9.6 - Has difficulty copying from the blackboard *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 10.1 - When reading out loud, has difficulty pronouncing words *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 10.2 - Has poor expression & a tendency to mumble when reading out loud *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 10.3 - When reading tends to misspell the words that sound similar (cheap, sheep, ship, chip) *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1
Section 10.4 - Has difficulty with note taking *
0=never or rarely. 1=sometimes. 2=often. 3=always. N/A - not applicable (e.g. child is too young)
0
1
2
3
N/A
Row 1