Name *

First Name

Last Name

Your Child's Name

First Name

Last Name

Phone *

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1. Developmental History: Our early years

This knowledge about our younger years is extremely important in early identification and prevention of listening problems. It also sheds light on possible causes of listening problems.

A stressful pregnancy

Difficult birth

Adoption

Early separation from the mother

Delay in motor development

Delay in language development

Recurring ear infections

2. Receptive Listening: Our external environment

This type of listening is directed outward to the world around us. It keeps us attuned to what’s going on at home, at work, in the classroom or with friends.

Short attention span

Distractibility

Over-sensitivity to sounds

Misinterpretation of questions

Confusion of similar-sounding words

Frequent need for repetition

Inability to follow sequential instructions

3. Expressive Listening: Our internal atmosphere

This is the kind of listening that is directed within us. We use it to listen to ourselves and to gauge and control our voice when we speak and sing.

Flat and monotonous voice

Hesitant speech

Weak vocabulary

Poor sentence structure

Overuse of stereotyped expressions

Inability to sing in tune

Confusion or reversal of letters

Poor reading comprehension

Poor reading aloud

Poor spelling

4. Motor Skills: Our physical abilities

The ear of the body (the vestibule), which controls balance, muscle and eye coordination and body image needs close scrutiny also.

Poor posture

Fidgety behavior

Clumsy, uncoordinated movements

Poor sense of rhythm

Messy handwriting

Hard time with organization, structure

Confusion of left and rights

Mixed dominance (of hands?)

Poor sports skills

5. The Level of Energy: Our fuel system

The ear acts like a dynamo (a powerful motor), providing us with the “brain” energy we need to not only to survive but also to lead fulfilling lives.

Difficulty getting up

Tiredness at the end of the day

Habit of procrastinating

Hyperactivity

Tendency toward depression

Feeling overburdened with everyday tasks

6. Behavioral and Social Adjustment: Our relationship skills

Listening difficulty is often related to these qualities of interacting with others.

Low tolerance for frustration

Poor self-confidence

Poor self-image

Shyness

Difficulty making friends

Tendency to withdraw or to avoid others

Irritability

Immaturity

Low motivation, no interest in school/work

Negative attitude toward school/work

Do you/your child have a history of seizures?

Yes

No

Do you/your child have ringing in the ear (tinnitus)?

Yes

No

Do you/your child have a history of hallucinations?

Yes

No

Do you/your child have been diagnosed with a psychiatric disorder?

Yes

No

Do you/your child have a history of ear infections?

Yes

No

Do you/your child have Menier's?

Yes

No