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Auditory Processing Disorder Test - Self Report
Assessment 1 of 23
Form Instructions & Things to Know
How to fill this form:
Read each question carefully before selecting an answer.
Select the most accurate option based on your observations.
Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins
Estimated completion time.
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Your data is fully encrypted.
Note:
This is a screening and assessment tool, not clinical (medical).
First, please provide your contact information.
Your Full Name
Email Address
Phone Number
Information about the individual being assessed.
Who are you filing for?
Choose relationship...
Self
Child
Partner
Family Member
Friend
Caretaker
Guardian
Teacher/Tutor
Name of Individual Being Assessed
Date of Birth
Age
Gender
*
Select Gender
Male
Female
School Grade (Optional)
Assessment Reasons / Reason for Assessment
1. I struggle to follow conversation in restaurants, parties, or other noisy places.
Never
Rarely
Sometimes
Often
Very often
2. Background noise, like a fan, TV, or hallway chatter, makes it hard for me to focus on what someone is saying.
Never
Rarely
Sometimes
Often
Very often
3. I have trouble following a conversation when more than one person is talking at once.
Never
Rarely
Sometimes
Often
Very often
4. I find it hard to follow speech on a phone or video call when there's background noise on either end.
Never
Rarely
Sometimes
Often
Very often
5. Noisy classrooms, meeting rooms, or open-plan offices make it hard for me to catch what's said.
Never
Rarely
Sometimes
Often
Very often
6. I mishear words that sound similar, like "fifteen" and "fifty," or mix up similar-sounding words.
Never
Rarely
Sometimes
Often
Very often
7. I ask people to repeat themselves, even in quiet settings, more often than people around me seem to.
Never
Rarely
Sometimes
Often
Very often
8. Fast talkers or people with unfamiliar accents are especially hard for me to understand.
Never
Rarely
Sometimes
Often
Very often
9. I struggle to tell which direction a sound, like someone calling my name, is coming from.
Never
Rarely
Sometimes
Often
Very often
10. I find myself watching someone's mouth or face to understand them, even when I can hear their voice fine.
Never
Rarely
Sometimes
Often
Very often
11. I forget spoken instructions almost as soon as I've heard them.
Never
Rarely
Sometimes
Often
Very often
12. When someone gives me several steps at once, I only remember the first or last one.
Never
Rarely
Sometimes
Often
Very often
13. I have to write things down immediately after hearing them, or I lose the information.
Never
Rarely
Sometimes
Often
Very often
14. I find it hard to hold a phone number, address, or short list in my head after hearing it once.
Never
Rarely
Sometimes
Often
Very often
15. I mix up the order of steps when following spoken directions.
Never
Rarely
Sometimes
Often
Very often
16. Listening carefully for a long stretch, like in a lecture or meeting, leaves me mentally exhausted
Never
Rarely
Sometimes
Often
Very often
17. My mind drifts during conversations, even when I am genuinely trying to listen.
Never
Rarely
Sometimes
Often
Very often
18. Long phone calls or video calls wear me out more than they seem to wear out other people.
Never
Rarely
Sometimes
Often
Very often
19. By the end of a loud or conversation-heavy day, I feel unusually drained or foggy.
Never
Rarely
Sometimes
Often
Very often
20. I find it hard to listen and take notes, or listen and think something through, at the same time.
Never
Rarely
Sometimes
Often
Very often
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