Auditory Training Assesment Brain Training Assessment This listening screening tool is provided to help you identify possible areas of weakness related to auditory functions. This is not intended as a diagnostic tool. This tool was developed to help you understand areas where Brain Works auditory training may be of particular benefit. Name of person completing screening*Relationship to person being screened*Email* Enter Email Confirm Email Phone*Best time to call* Morning Afternoon Evening Check all that apply.Name of person being screened*GenderFemaleMaleAgePlease enter a value between 0 and 120.CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweReason for screeningPlease read each of the following statements and check all that apply.Listening & Auditory Processing inattentive while listening some sounds are too loud poor listening memory bothered by background noise misinterpretation of questions difficulty following verbal directions Check all that apply.Speech, Language, & Reading poor speech articulation or mumbling weak vocabulary poor sentence structure - written or verbal difficulty reading poor visual memory poor speller Check all that apply.Motor Skills & Sensory Integration sensitive to touch, sound, taste or light hyperactive, fidgety, or hypo-active clumsy, uncoordinated movements unaware of pain, touch, temperature messy handwriting poor hand-eye coordination Check all that apply.Focus & Attention Span short attention span easily distracted by sound or environment easily discouraged habit of procrastinating restless while sleeping feeling overburdened with everyday tasks Check all that applyCognition difficulty making decisions not understanding jokes or metaphors impulsive, acting before thinking hard time getting organized not creative with problem solving poor mental energy Check all that applyMood and Social Behavior low tolerance for frustration negative thinking tendency toward anxiety or depression difficulty making friends, tend to be alone make frequent social mistakes immature behavior compared to peers Check all that applyThe information being collected in this listening screening tool will not be shared with any third party, unless it is a third-party referral or other medical professional AND you have given us express permission to do so. By pressing "submit" below, you acknowledge and agree to these terms.