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?

YesNo

Any current program of remediation?

YesNo

 

Child Symptoms:

 

Any difficulties during pregnancy?

YesNo

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

YesNo

Cried a lot in infancy?

YesNo

Responded to early interactive play?

YesNo

Began to speak and regressed?

YesNo

Prone to ear infections?

YesNo

Slow development?

YesNo

Poor eye contact?

YesNo

Limited speech?

YesNo

Screams or laughs for no apparent reason?

YesNo

Unusual or limited food preferences?

YesNo

Disturbed sleep patterns?

YesNo

Sensitive to some sounds?

YesNo

Dislikes being touched?

YesNo

Behaviour problems?

YesNo

Temper tantrums?

YesNo

Any allergies?

YesNo

Suffers from Asthma?

YesNo

Suffers from Epilepsy?

YesNo

Bed wetting after 5 yrs?

YesNo

Mood swings?

YesNo

Fidgety?

YesNo

Unusually anxious and fearful?

YesNo

Accident prone?

YesNo

Hyperactive?

YesNo

Aggressive?

YesNo

Injures self or others?

YesNo