Early history of ear infections/ glue ear/ or hearing problems prior to age three?:
Yes
No
Persisting middle ear infections/ glue ear/ hearing problems/grommets or ENT operations beyond age three?:
Yes
No
Family history of speech, reading or spelling difficulties (including reluctant readers)?:
Yes
No
Family or school circumstances which may have affected the child’s development?:
Yes
No
CONCENTRATION, ATTENTION, LISTENING AND UNDERSTANDING
Daydreams in class?:
Yes
No
Disruptive in class (possibly because they can’t follow teacher for prolonged period)?:
Yes
No
Difficulty following through instructions – needs to check with teacher/ classmate to be sure?:
Yes
No
Difficulty coping with background noise or works better 1 to 1 than in class?:
Yes
No
Does not always respond when name is called or when being addressed as part of a group?:
Yes
No
Appears not to listen to what is being said?:
Yes
No
Evidence of standing back to see what others are doing before following a verbal instruction?:
Yes
No
Difficulty listening or following instructions while doing something?:
Yes
No
Difficulty listening and taking notes simultaneously?:
Yes
No
Homework takes much longer to complete than it should?:
Yes
No
Difficulty settling down to independent work?:
Yes
No
Tends to take things too literally for their age?:
Yes
No
Difficulty making/ sustaining friendships (slow processing may cause difficulties keeping up with fast-paced banter of peer group):
Yes
No
Oversensitivity to/ dislike of loud or particular sounds?:
Yes
No
SPEECH
Speech poorly articulated or slow, hesitant or confused?:
Yes
No
Intonation flat or monotonous?:
Yes
No
Word finding problems – struggles to find the word they want to say?:
Yes
No
Confusion/ difficulty saying multi-syllabic words?:
Yes
No
Difficulty initiating/ maintaining conversation or asking questions?:
Yes
No
READING, SPELLING AND NUMERACY:
Difficulty with decoding/ encoding?:
Yes
No
Appears not to hear the sounds/ sound sequence in words?:
Yes
No
Difficulty with layout of work?:
Yes
No
Difficulty with maths?:
Yes
No
Has your child had any specialist assessments E.G. Educational Psychologist, Speech and Language, Physio or Occupational Therapist, Specialist Teacher? Who and when?
Yes
No
Please add any further information or comments about your child’s hearing, listening and attention?