Listening and Language Questionnaire
This questionnaire is designed to provide information about the client’s auditory processing skills and the effect that they are having on language, communication, behavior, learning, and motor skills.
Student Information:
Name: *
Your answer
Age *
Your answer
Filled-Out By: *
Your answer
Relationship/Title: *
Your answer
Email Address: *
The email address provided will be used solely for the purposes of Sound Foundations For Learning. It will not be sold to external sources.
Your answer
Developmental and Environmental History (Please check if applicable)
Questionnaire:
Response Choices: Not a problem-0 Seldom-1 Sometimes-2 Often-3 Very Often-4
Ability to Understand What Other People Say *
0
1
2
3
4
Needs to have information or instructions repeated
Says, “Huh?” or “What?”
Confuses similar sounding words
Has difficulty understanding discussions
Has difficulty following conversations
Has difficulty remembering / following more than one or two directions
Has trouble understanding humor / jokes
Listening Skills and Auditory Memory *
0
1
2
3
4
Easily distractible when listening
Short auditory attention span
Oversensitive to certain sounds
Tires easily
Becomes sleepy when listening to speakers
Feels that people talk too fast
Gets confused in noisy situations
Trouble with sound discrimination (phonemic awareness)
Daydreams or tunes out in class
Difficulty hearing and understanding in background noise such as TV, others talking, music, children playing, etc.
Difficulty hearing and understanding in a quiet room (others may be present but are being quiet)
Difficulty listening when there is also some other form of input (such as watching speaker’s face, a demonstration or illustration, listening to another read and reading along)
Trouble immediately recalling spoken information
Trouble recalling spoken information (such as instructions, word spelling, numbers, etc.) when delayed recollection is required (1 hour or more)
Trouble remembering order or sequence of spoken information
Oral Communication Skills *
0
1
2
3
4
Delay in speech or language development
Has a slow or delayed response
Monotone voice quality
Speech lacks fluency and rhythm
Difficulty with word retrieval (finding the words he/she wants to say)
Uses “Um” when speaking
Uses vague language
Confuses prepositional words such as “on” and “in”
Difficulty speaking in complete sentences
Poor grammar
Difficulty organizing and expressing thoughts
Tendency to ramble when retelling or explaining
Uses few descriptive words
Difficulty summarizing
Difficulty reconstructing a story in appropriate order
Difficulty giving a meaningful account of the events of the day
Difficulty speaking in front of the class or a group
Difficulty getting started with open-ended questions
Mispronounces words
Loses his/her way in sentences or fails to finish longer sentences
Speaks mostly in phrases or single sentences. Does not elaborate
Trouble articulating, or saying, certain sounds
Avoids typical interactions with strangers in noisy environments (such as ordering at a fast food counter)
Trouble talking on the phone
Trouble rephrasing a point if he/she is not understood the first time
Difficulty using humor
Academic, School and Work Skills *
0
1
2
3
4
Difficulty with phonics
Difficulty with reading fluency
Difficulty with reading comprehension
Difficulty with spelling
Can memorize words for spelling tests but cannot retain over time
Difficulty remembering questions when called upon in class or meetings
Difficulty with math concepts
Difficulty with math calculations and math facts
Difficulty with written expression
Difficulty with writing mechanics (capitalization, punctuation, etc.)
Behavior and Social Skills *
0
1
2
3
4
Low frustration tolerance
Poor self image or low self-esteem
Difficulty making or keeping friends
Withdraws from or avoids social interactions
Mood swings or moodiness
Tendency toward irritability
Tends to be anxious or tense
Low motivation
Difficulty getting started
Difficulty completing tasks
Poor planning and organization skills
Difficulty with time concepts and punctuality
Difficulty “reading” body language, facial expressions, and tone of voice.
Tends to be forgetful
Lacks tact
Difficulty making judgments and generalizing to new situations
Energy Level *
0
1
2
3
4
Excessively tired at the end of the day
Procrastinates
Hyperactive
Tendency toward depression
Trouble getting self going in the morning
Very slow moving
Motor Skills *
0
1
2
3
4
Poor balance or coordination
Tends to be clumsy or awkward
Excessive body movement when speaking
Poor posture, including slouching and slumping
Confusion with right and left
Confusion about location and direction
Poor sense of rhythm
Poor handwriting
©2010 Moyers Learning Systems All rights reserved
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.