Adult Checklist
This checklist is designed to help an adult access whether they
might be having problems with their auditory system.
Check off any item that applies to you. If you check off many items, read about Auditory Integration Training and consider scheduling an auditory assessment
Name.................................. Date of birth...............
Tel...................................... Date......................
1. History of hearing loss
2. History of middle ear infections
3. Has difficulty following verbal directions
4. Has difficulty following conversations
5. Often forgets what is said
6. Often requests that verbal instructions be repeated
7. Always needs the TV on louder than everyone else
8. Rely on lip-reading, gesture, context -- or just plain guessing -- to understand what is being said
9. Easily distracted by background noise
10. Frequently misunderstands what is said
11. Impulsive
12. Says what and/or what?
13. Slow processing of auditory input
14. Has short attention span
15. Daydreams, attention drifts
16. Easily distracted by sound
17. Cannot attend to purely auditory input for long periods of time
18. Ability to work deteriorates in groups or crowds
19. Experiences problems with sound discrimination
20. Often frustrated
21. Have low self-esteem and/or lacks confidence
22. Experience painful discomfort with sounds that others
find untroublesome
23. Notices sounds before others do
24. Is startled by sounds and movement that don't bother
anyone else
25. Never fully completes tasks
26. Need frequent "quiet time" to regain mental energy
and composure
27. Can be irritable or picky "by nature"
28. Often depressed without identifiable cause
29 Often negative without identifiable cause
30. Has a problem relating a story or event(long winded)
31. Have difficulty organizing the day
32. Experience growing fatigue as the day progresses
33. Have difficulty keeping track of a sequence of actions
34. Have difficulty taking notes during speeches or lectures
35. Withdraws socially (introvert)
36. Inconsistencies of performance and of errors
37. Notice that sounds upset or agitate me but not others
38. Gives unusual descriptions of sounds
39. Constant humming or audible self-talk
40. Is considered to have a learning disability, ADD, ADHD, CAPD, hypersensitive or hypo-sensitive hearing, speech defect
(stuttering or lisp)
TOTAL =
THIS AUDITORY PROBLEMS CHECKLIST WAS COMPILED AS PART OF A RESEARCH PROJECT INTO AUDITORY PROCESSING PROBLEMS IN CHILDREN AND ADULTS, WITH REFERENCE TO THE FISCHER'S APC AND THE WORKS OF A.J. KATZ.
Thank you for your co-operation
Khymberleigh D. Herwill-Levin
(Auditory Integration Practitioner)
Signature.............................................................
Date..................................................................
