BUFFALO MODEL QUESTIONNAIRE - REVISED
Simplified Adult Form

Please complete the following prior to your appointment

Please fill in your details below:

First Name*

Last Name

Email*

Contact Number*

🇦🇺

Age

DOB

Please indicate if you are currently receiving or have received any of the services by providing the number of years otherwise leave blank.

Auditory training?

Speech therapy?

Phonological awareness training?

Special phonics training?

Special help with reading?

Sensory-integration training?

Please select YES if the statement applies to you or NO if it is not a problem.

DEC

I have a problem saying speech sounds

YES

I have a problem understanding language

YES

I have a problem understanding spoken instructions

YES

I have a problem reading aloud

YES

I have a problem with phonics

YES

I have a problem with spelling

YES

I respond slowly/delayed to spoken language

YES

I may have a problem learning foreign language

YES

Never attempted foreign language learning

I speak slowly

YES

NOI

I am hypersensitive to noise

YES

I am distracted by noise

YES

I struggle to understand speech in noise

YES

I am noisy/makes more noises in comparison to my peers

YES

MEM

I respond too quickly, at times

YES

I interrupt frequently others talking

YES

I have a problem with reading comprehension

YES

I speak quickly

YES

I forget things I have been told

YES

I have a problem remembering spoken instructions

YES

VAR

I have a problem paying attention

YES

I have a problem using language

YES

I may have ADHD/ADD

YES

I have anxiety (e.g., new situations)

YES

INT

I have extremely poor handwriting

YES

I have a problem integrating auditory and visual info

YES

I have significant reading/spelling difficulties

YES

I may have significant visual perception difficulties

YES

I sometimes have very long delays in responding

YES

I have Dyslexia

YES

ORG

I have a problem keeping things in organized

YES

I have a problem sequencing verbal items/information

YES

I am messy/tends to lose things

YES

APD

I have a history of ear infections / ear fluid as a child

YES

I have a problem understanding what is said

YES

I have a learning disability

YES

I have a problem following spoken instructions

YES

I have an intellectual disability

YES

I have had a head injury

YES

I have Autism or a related problem

YES

GEN

I am hypersensitive to touch

YES

I have a problem maintaining eye contact with a speaker

YES

I have a problem with long-term memory

YES

I may have a psychological problem

YES

I may have a behavior problem

YES

I have a problem with coordinating body movements

YES

I may have allergies

YES

I have a problem learning math concepts

YES

I have a hearing problem

YES

Audiologist to complete

D	N	M	V	TFM	I	O	APD	ΣCAP	G
/9	( /4)	( /6)	( /4)	/14	/6	/3	/7	/39	( /9)

BUFFALO MODEL QUESTIONNAIRE - REVISEDSimplified Adult Form

Please complete the following prior to your appointment

BUFFALO MODEL QUESTIONNAIRE - REVISED
Simplified Adult Form