Mobile navigation
Staff Area
Search
Home
Patients and Visitors
Patients and Visitors
Return to previous menu
Patients and Visitors
Travelling to and from our hospitals
Travelling to and from our hospitals
Return to previous menu
Travelling to and from our hospitals
Our Locations
Patient Transport Service & Healthcare Travel Costs Scheme
Community Transport & Volunteer Driver Services
Car Parking
Public Transport
Your care with us
Your care with us
Return to previous menu
Your care with us
Emergency care
Inpatient care
Outpatient care
Community care
Hospital discharge - information for patients and families
Patient Initiated Follow Up (PIFU)
Visiting times and information
Visiting times and information
Return to previous menu
Visiting times and information
Wards and departments
Chaplaincy services
Hospital radio
Wi-Fi
Caring for our patients
Caring for our patients
Return to previous menu
Caring for our patients
Our focus on safety and quality
How we use your information
Overseas patients
Cafés, shops and amenities
Share your feedback
Share your feedback
Return to previous menu
Share your feedback
Advice and Complaints
Healthwatch
Share your feedback online
Patient Experience Surveys
Join our Online Community
Supporting our carers
NHS Accessible Information Standard
Coming to hospital if you have a learning disability
Sending Love
Smokefree
Medical Examiners Office
Our commitment to cleanliness
Preparing for your surgery
Changing Places
Returning walking aids - drop off points
Patient Safety
Services
About Us
About Us
Return to previous menu
About Us
About us
Our vision and values
Our strategic framework
Our strategic framework
Return to previous menu
Our strategic framework
Our five year strategies for STSFT
Our leadership team
Our specialist services
Our board
Our board
Return to previous menu
Our board
Meeting times, agendas and papers
Our governors
Our governors
Return to previous menu
Our governors
Meeting times, agendas and papers
Corporate information
Corporate information
Return to previous menu
Corporate information
Reports and publications
Learning from deaths
Freedom of Information Requests
Countering fraud
Finance information
Our subsidiaries
Equality, diversity and inclusion
Working in partnership across the North East and North Cumbria
Population Health
Population Health
Return to previous menu
Population Health
Fruit & Veg stall trial
Our pathway to Nursing and Midwifery Excellence
Our pathway to Nursing and Midwifery Excellence
Return to previous menu
Our pathway to Nursing and Midwifery Excellence
Pathway to Excellence Staff Survey
Organ Donation
Small changes, BIG impact
Small changes, BIG impact
Return to previous menu
Small changes, BIG impact
Small changes, BIG impact feedback form
News
News
Return to previous menu
News
Latest news
Mobile phone and photography restrictions
Media enquiries
Media enquiries
Return to previous menu
Media enquiries
Our links
Media Consent Form: Patient, public and staff
Our People Podcast
Contact Us
Contact Us
Return to previous menu
Contact Us
Freedom of information requests
Our Charity
Our Charity
Return to previous menu
Our Charity
About us
About us
Return to previous menu
About us
Our Funds
Our Volunteer Fundraisers
The Charitable Funds Committee
Events
Events
Return to previous menu
Events
The Big Tea
Donate now
Donate now
Return to previous menu
Donate now
Donate by cheque
Support Us
Support Us
Return to previous menu
Support Us
Volunteer Fundraiser
Give when you shop
Gifts in Wills
Corporate Partners
St Benedict's Hospice
Appeals & Campaigns
Appeals & Campaigns
Return to previous menu
Appeals & Campaigns
Vision Appeal
Events
Paediatric Forms
LittlEars Auditory Questionnaire
Parent’s questionnaire to assess auditory behaviour
Your Information
Full name
Required
Date of Birth
Required
Post Code
Required
Date Questionnaire Completed
Required
Auditory Response
Does your child respond to a familiar voice?
Required
** None
Yes
No
Does your child listen to somebody speaking
Required
** None
Yes
No
When somebody is speaking does your child turn his/her head towards the speaker
Required
** None
Yes
No
Is your child interested in toys producing sounds or music
Required
** None
Yes
No
Does your child look for a speaker he/she can not see?
Required
** None
Yes
No
Does your child listen when the radio/CD player/MPS player is turned on?
Required
** None
Yes
No
Does your child respond to distant sounds?
Required
** None
Yes
No
Does your child stop crying when you speak to him/her without him/her seeing you?
Required
** None
Yes
No
Does your child respond with alarm when hearing and angry voice?
Required
** None
Yes
No
Does your child recognise acoustic rituals?
Required
** None
Yes
No
Does your child look for sound sources located to the left, right or back?
Required
** None
Yes
No
Does your child react to his/her name?
Required
** None
Yes
No
Does your child look for sound sources located above or below?
Required
** None
Yes
No
When your child is sad or moody, can he/she be calmed down or influenced by music?
Required
** None
Yes
No
Does your child listen on the telephone and does he/she seem to recognise that somebody is talking?
Required
** None
Yes
No
Does your child respond to music with rhythmical movement?
Required
** None
Yes
No
Does your child know that a certain sound is related to a certain object or event?
Required
** None
Yes
No
Does your child appropriately respond to short and simple remarks?
Required
** None
Yes
No
Does your child respond to “No” by typically interrupting his/her current play?
Required
** None
Yes
No
Does your child know family members’ names?
Required
** None
Yes
No
Does your child imitate sounds when asked?
Required
** None
Yes
No
Does your child follow simple commands?
Required
** None
Yes
No
Does your child understand simple questions?
Required
** None
Yes
No
Does your child bring items when asked ?
Required
** None
Yes
No
Does your child imitate sound or words you make?
Required
** None
Yes
No
Does your child produce the right sound to a toy?
Required
** None
Yes
No
Does your child know that certain sounds go with certain animals ?
Required
** None
Yes
No
Does your child try to imitate environmental sounds?
Required
** None
Yes
No
Does your child correctly repeat a sequence of short and long syllables you have said?
Required
** None
Yes
No
Does your child select the right object from a number of objects when asked?
Required
** None
Yes
No
Does your child try to sing along when hearing a song?
Required
** None
Yes
No
Does your child repeat certain words when asked?
Required
** None
Yes
No
Does your child like being read to?
Required
** None
Yes
No
Does your child follow complex commands?
Required
** None
Yes
No
Does your child try to sing with familiar songs?
Required
** None
Yes
No
Additional questions we are interested in:
Have you observed any responses to sound or voices in your child that are not included in the questionnaire?
Required
Have you noticed any surprising responses to sound or voices in your child recently or in the last 1-2 weeks (i.e. can he/she do this already?)
Required
Hearing Age
Children with normal hearing: hearing age is equivalent to actual age (months)
Required
Children with HA(s): time period since hearing aid fitting (months)
Required
Privacy Policy
I agree to the
privacy policy
Submit
Return to Audiology
Hide this section
Show accessibility tools
Home
Patients and Visitors
Patients and Visitors
Travelling to and from our hospitals
Travelling to and from our hospitals
Our Locations
Our Locations
Sunderland Royal Hospital
Sunderland Eye Infirmary
Clarendon
South Tyneside District Hospital
Niall Quinn Children's Centre
Palmer Community Hospital
Sunderland Children's Centre
Durham Treatment Centre
St Benedict's Hospice
Elmville Unit, Monkton Hall
Haven Court
Intermediate Care Assessment and Rehabilitation (ICAR)
Patient Transport Service & Healthcare Travel Costs Scheme
Community Transport & Volunteer Driver Services
Car Parking
Car Parking
Blue Badge Holder Parking Registration Form
Public Transport
Your care with us
Your care with us
Emergency care
Emergency care
Strike action 14-17 June
Inpatient care
Outpatient care
Community care
Hospital discharge - information for patients and families
Patient Initiated Follow Up (PIFU)
Visiting times and information
Visiting times and information
Wards and departments
Chaplaincy services
Hospital radio
Wi-Fi
Caring for our patients
Caring for our patients
Our focus on safety and quality
How we use your information
Overseas patients
Cafés, shops and amenities
Share your feedback
Share your feedback
Advice and Complaints
Advice and Complaints
Feedback
Healthwatch
Share your feedback online
Patient Experience Surveys
Join our Online Community
Supporting our carers
NHS Accessible Information Standard
Coming to hospital if you have a learning disability
Sending Love
Smokefree
Medical Examiners Office
Our commitment to cleanliness
Preparing for your surgery
Changing Places
Returning walking aids - drop off points
Patient Safety
Services
About Us
About Us
About us
Our vision and values
Our strategic framework
Our strategic framework
Our five year strategies for STSFT
Our leadership team
Our specialist services
Our board
Our board
Meeting times, agendas and papers
Meeting times, agendas and papers
South Tyneside and Sunderland NHS Foundation Trust
Past meetings, agendas and papers (STFT)
Past meetings, agendas and papers (CHSFT)
Past meetings, agendas and papers (STSFT)
Our governors
Our governors
Meeting times, agendas and papers
Meeting times, agendas and papers
South Tyneside and Sunderland NHS Foundation Trust
Past meetings, agendas and papers (STFT)
Past meetings, agendas and papers (CHSFT)
Past meetings, agendas and papers (STSFT)
Corporate information
Corporate information
Reports and publications
Learning from deaths
Freedom of Information Requests
Freedom of Information Requests
Publication Scheme
FOI Feedback
Countering fraud
Finance information
Our subsidiaries
Equality, diversity and inclusion
Working in partnership across the North East and North Cumbria
Population Health
Population Health
Fruit & Veg stall trial
Our pathway to Nursing and Midwifery Excellence
Our pathway to Nursing and Midwifery Excellence
Pathway to Excellence Staff Survey
Organ Donation
Small changes, BIG impact
Small changes, BIG impact
Small changes, BIG impact feedback form
News
News
Latest news
Mobile phone and photography restrictions
Media enquiries
Media enquiries
Our links
Our links
Christmas Message
Just Eat Form
CHoiCE Staff Survey Prize Draw
Choice Recruitment Event Reigstration
Media Consent Form: Patient, public and staff
Our People Podcast
Contact Us
Contact Us
Freedom of information requests
Our Charity
Our Charity
About us
About us
Our Funds
Our Volunteer Fundraisers
The Charitable Funds Committee
Events
Events
The Big Tea
Donate now
Donate now
Donate by cheque
Support Us
Support Us
Volunteer Fundraiser
Give when you shop
Gifts in Wills
Corporate Partners
St Benedict's Hospice
Appeals & Campaigns
Appeals & Campaigns
Vision Appeal
Events
