Auditory Processing Review (APD) Patient Name & Age Patient Name Age Date of Birth* Date Format: MM slash DD slash YYYY Today's Date* Date Format: MM slash DD slash YYYY Person completing this formRelationship to childReferring PhysicianSchoolGradeTeacherClassroom Type Traditional Open Podium Portable Student’s preferred hand Right Left Development History1. Were there complications during the pregnancy? Yes No If yes, describe2. Were there complications during the birth? Yes No If yes, describe3. Did your child have a premature birth? Yes No If yes, how many weeks?What was your child’s APGAR score?What was your child’s birth weight?4. Has your child had any serious illness or accidents? Yes No If yes, describePlease check if your child had any of the following: Fetal alcohol syndrome Hyperbilirubinemia Bacterial Meningitis Congenital Perinatal infections Ototoxic medication Mechanical Ventilation Fever over 104° F Maternal substance abuse Asphyxia Head/neck deformity Craniofacial abnormalities Syndromal abnormality Otological History1. Does your child have a history of ear problems? Yes No Please check all that apply Ear infections Excessive ear wax Fluid behind the ear Ear aches Tubes in the ear Soreness/pain in the ears Ear canal discharge Hole/perforated eardrum Other:2. How many episodes of ear problems since birth?3. Has your child had an ear infection in the last 6 months? Yes No If yes, when?What type?Was medication given? Yes No What?4. Is there a family history of ear problems? Yes No If yes, who?What type?Was medication given? Yes No What?5. Has your child ever been treated by an Ear, Nose & Throat (ENT) doctor? Yes No If yes, who?When? For What?Was medication given?6. Has your child ever had ear surgery? Yes No If yes, describe:When?7. Has your child previously had his/her hearing tested by an Audiologist? Yes No If yes, where?When?8. Has your child had any permanent hearing loss? Yes No If yes, describe:Has your child ever used amplification?Other History1. Does your child have any learning problems? Yes No If yes, explain:Has your child been evaluated for learning problems? Yes No 2. Does your child have any speech or language problems? Yes No If yes, explain:Has your child been evaluated by a Speech Language pathologist? Yes No Is your child receiving speech therapy? Yes No How Often?3. Does your child have any known attention deficit or hyperactivity problems? Yes No If yes, explain:4. Does your child have any known behavioural problems? Yes No If yes, explain:Listening and Understanding1. Do you think your child has problems listening or understanding? Yes No If yes, explain:How long have you been aware of this problem?2. Does your child have difficulties with any subjects at school? Yes No If yes, please list:3. What are your child’s best subjects in school?4. Does your child participate in any special class(es) or therapies? Yes No If yes, please describe:5. Has your child been tutored? Yes No If yes, please describe:Behaviour and Characteristics:Can the Fever 104 F can be change to 40 C? Yes No Please check if your child exhibits any of the following behaviours or characteristics. Extremely sensitive to loud sounds Appears confused in a noisy place Easily upset by new situations Difficulties following and/or understanding TV program Difficulties following directions or instructions Does opposite of what is requested Restless; problem sitting still Overly active Short attention span Impulsive Easily distracted Poor listener Says “what” or “huh”? Difficulties recalling short or long term information Difficulties with time concept Daydreams Forgetful Often asks for repetition Reverses words, number, or letters Prefers to play with older children Prefers to play with younger children Prefers solitary activities Seeks attention Disruptive or rowdy Temper tantrum Shy Anxiety Lack self-confidence Reluctant to try new task Give inappropriate responses to questions Lacks motivation Uncooperative Disobedient Destructive Inappropriate social behaviour Difficulties or does not complete assignments Easily frustrated Tires easily Irritable Dislike school Fakes / exaggerates illness Awkward/clumsy Depressed Uncoordinated or disorganised Difficulties reading or writing This iframe contains the logic required to handle Ajax powered Gravity Forms. Adapted from APD Case History: Child by Eva M. Chiu, Au.D.