BUFFALO MODEL QUESTIONNAIRE - REVISED
Simplified Child Form

Please complete the following prior to your appointment

Please fill in your details below:

First Name*

Last Name

Email*

Contact Number*

🇦🇺

Please fill in your child's details below:

Child's Name

Child's Age

Child's 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

My child has a problem saying speech sounds

YES

My child has a problem understanding language

YES

My child has a problem understanding spoken instructions

YES

My child has a problem reading aloud

YES

My child has a problem with phonics

YES

My child has a problem with spelling

YES

My child responds slowly/delayed to spoken language

YES

My child has a problem learning foreign language

YES

Never attempted foreign language learning

My child speaks slowly

YES

NOI

My child is hypersensitive to noise

YES

My child is distracted by noise

YES

My child struggles to understand speech in noise

YES

My child is noisy/makes more noises in comparison to their peers

YES

MEM

My child responds quickly, at times

YES

My child frequently interrupts others talking

YES

My child has a problem with reading comprehension

YES

My child speaks quickly

YES

My child forgets things they have been told

YES

My child has a problem remembering spoken instructions

YES

VAR

My child has a problem paying attention

YES

My child has a problem using language

YES

My child has ADHD/ADD

YES

My child has anxiety (e.g., new situations)

YES

INT

My child has extremely poor handwriting

YES

My child has a problem integrating auditory and visual info

YES

My child has significant reading/spelling difficulties

YES

My child has significant visual perception difficulties

YES

My child sometimes has very long response delays

YES

My child has Dyslexia

YES

ORG

My child has a problem keeping things in organized

YES

My child has a problem sequencing verbal items/information

YES

My child is messy/tends to lose things

YES

APD

My child has a history of ear infections / ear fluid as a child

YES

My child has a problem understanding what is said

YES

My child has a learning disability

YES

My child has a problem following spoken instructions

YES

My child has an intellectual disability

YES

My child has had a head injury

YES

My child has Autism or a related problem

YES

GEN

My child is hypersensitive to touch

YES

My child has a problem maintaining eye contact with a speaker

YES

My child has a problem with long-term memory

YES

My child has a psychological problem

YES

My child has a behavior problem

YES

My child has a problem coordinating body movements

YES

My child may have allergies

YES

My child has a problem learning math concepts

YES

My child has 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 Child Form

Please complete the following prior to your appointment

BUFFALO MODEL QUESTIONNAIRE - REVISED
Simplified Child Form