Questionnaire

Please take a few minutes to complete this Auditory Integration Training (AIT) Questionnaire and provide information about your child so that we can tell you if we can help.

Your Details:

 



Country:

 

Child's Details:

 





Has s/he been statemented?

 Yes No

Any current program of remediation?

 Yes No

 

Child Symptoms:

 

Any difficulties during pregnancy?

 Yes No

Was birth caesarean, induced, long labour or particularly difficult?

 Yes No

Cried a lot in infancy?

 Yes No

Responded to early interactive play?

 Yes No

Began to speak and regressed?

 Yes No

Prone to ear infections?

 Yes No

Slow development?

 Yes No

Poor eye contact?

 Yes No

Limited speech?

 Yes No

Screams or laughs for no apparent reason?

 Yes No

Unusual or limited food preferences?

 Yes No

Disturbed sleep patterns?

 Yes No

Sensitive to some sounds?

 Yes No

Dislikes being touched?

 Yes No

Behaviour problems?

 Yes No

Temper tantrums?

 Yes No

Any allergies?

 Yes No

Suffers from Asthma?

 Yes No

Suffers from Epilepsy?

 Yes No

Bed wetting after 5 yrs?

 Yes No

Mood swings?

 Yes No

Fidgety?

 Yes No

Unusually anxious and fearful?

 Yes No

Accident prone?

 Yes No

Hyperactive?

 Yes No

Aggressive?

 Yes No

Injures self or others?

 Yes No