Name:
Date:
Please tick (√) the most suitable option.
Receptive Skills
Never
Sometimes Often
Always
Sometimes Often
Always
Short attention span.
Oversensitivity to high-pitched sounds.
Misinterpretation of written or spoken word.
Confusion between similar sounding words.
Need of repetition and explanation.
Easily disengaged; bored.
Difficulty keeping up in discussions.
Having the impression that people speak too
quickly.
Having the impression that people speak too
loudly.
Poor short-term memory.
Poor long-term memory.
Becoming sleepy or tired when listening or
reading.
Difficulty hearing low male voices.
Difficulty hearing high female voices.
Expressive Skills
Never
Flat and monotonous voice.
Hesitant speech.
Difficulty recalling exact word usage &
spelling.
Singing out of tune.
Difficulty with reading out loud.
Poor spelling.
Difficulty summarizing a story.
Difficulty relating isolated facts.
Any specific events that you recall where
you felt inhibited to speak?
1
Sensory Integration:
Listening And Developmental Issues Related To
Birth And Early Childhood:
The following list is related to the integration
of several sensory systems, such as balance,
co-ordination, body image, spatial awareness,
and our sense of time.
Tick (√) if any of the following apply.
___ Developmental delay
___ Delayed language development
Tick (√) if any of the following apply.
___ Recurring ear infections
___ Mother had stressful pregnancy
___ Poor posture, including slouching and slumping ___ Difficult delivery
___ Lacking sense of personal space and boundaries ___ Experienced early separation from mother
___ Unusual need for movement and or touch
( hospitalization of either mother or self,
___ Uncoordinated body movement
post-natal depression of mother, adoption)
___ Fidgeting behaviour
___ Recurring ear infections
___ Clumsiness
___ Had severe allergies
___ Confusion between right and left
___ Frequent use of antibiotics
___ Frequent confusion about location and direction ___ Experienced frightening events
___ Poor sense of rhythm
___ Experienced emotional trauma
___ Poor sports skills
___ Messy handwriting
___ Difficulty with organization and structure
Other Environmental Factors That May Affect
Listening:
Social Adaptation Related To Listening:
Tick (√)
Tick (√) if any of the following apply.
___ Exposure to loud sounds
___ Tinnitus
___ Any form of head trauma
___ Migraines, headaches
___ Tinnitus
___ Vertigo
___ Easily frustrated and impatient
___ Poor self-image or low self-confidence
___ Difficulty in making and keeping friends
___ Avoiding social gatherings and chit chat
___ Low motivation to learn new things
___ Tense or anxious even in neutral environments
___ Difficulty setting goals and priorities
___ Difficulty in completing projects
___ Difficulty with being on time
___ Does not tolerate stress well
if any of the following apply.
Listening And Foreign Language Learning:
All languages have different sound characteristics.
List the languages spoken in your home.
Other things you’d like us to be aware of?
Listening And Our Ability To Enjoy Life:
The ear stimulates the brain and nervous system.
Contact us
Tick (√) if any of the following apply.
___ Difficulty getting up
___ Tiredness all through the day
___ Tired half-way the afternoon
___ Habit of procrastinating
___ Tendency toward depression
___ Feeling overburdened, even with simple tasks
2
Joya Centre
49 Brougham Street
Nelson
New Zealand
Telephone: +64 3 539 1350
Email: [email protected]
Visit: www.joyacentre.co.nz