CHILD family questionnaire - ACCESS® hearing aids by earAccess®

Children’s Home Inventory for Listening Difficulties (C.H.I.L.D) Family Member Questionnaire

This questionnaire should take about 15 minutes to complete. It is a validated questionnaire to evaluate your child’s hearing.

Questions for Family Member to Answer

Try the following situations with your child or recall how your child has responded under these various situations. Everyone has some difficulty hearing clearly and understanding in some situations. Choose the level on the Understand-O-Meter (below on the right side) you think describes your child’s abilities most closely and place this number in the box next to each question. This can be very difficult but try to estimate the child’s listening abilities as best as you can.

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Country *

Child's Name *

First

Last

Age of the child *

Name of family member completing the questionnaire *

First

Last

Relationship to the child, e.g. mother, father or aunt

Email *

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Phone number *

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1. Sit next to your child and look at a book together or talk about something in front of you using familiar words and a normal conversational manner. Talk in a quiet place and sit so your child is not looking at your face as you talk together. How difficult does it seem for your child to hear and understand what you say?

Selected Value: 1

2. Gather your family together for a meal at home or in a fairly quiet restaurant. Sit across the table from your child and ask some questions about a familiar topic or event. How difficult does it seem for your child to hear and understand what you say?

Selected Value: 1

3. When your child is in his or her bedroom playing quietly, walk into the room and tell or ask the child something. Do not say the child’s name or try to get his or her attention first. How difficult does it seem for your child to hear and understand what you say?

Selected Value: 1

4. Watch a live-action TV show or movie with your child. Ask questions about what was said or events in the show that were understood by listening to the dialogue. (Show is seen for first time and is not captioned.) How difficult does it seem for your child to hear and understand what people on the TV or movie say?

Selected Value: 1

5. Observe your child playing inside with a friend, brother or sister. Watch for the other child to ask him or her to do something. How difficult does it seem for your child to hear and understand other children when they talk?

Selected Value: 1

6. When your child is watching TV or playing with a noisy toy, walk into the room and talk to him or her without first getting the child’s attention. How difficult does it seem for your child to hear and understand you when there is noise from the TV or toy?

Selected Value: 1

7. Call your child’s name from another room when he or she is not able to see you. How difficult does it seem for him or her to realize that you are calling?

Selected Value: 1

8. Use a clock radio or alarm when it is time for your child to get up. How difficult does it seem to be for him or her to hear an alarm clock or clock radio go off? If not clock is used, how difficult is it for him or her to hear your voice and wake up without having to be touched or shaken?

Selected Value: 1

9. Observe your child playing with a group of children inside a house. It’s noisy (birthday party, cub scouts, etc.). How difficult does it seem to be for your child to understand what the children are saying as they play as a group?

Selected Value: 1

10. A grandparent, family member or friend wants to talk to your child on the phone. How difficult does it seem to be for him or her to hear and understand what is said over the phone?

Selected Value: 1

11. Observe your child playing outside with other children. How difficult is it for him or her to hear and understand what other children are saying when the children are outside and are not standing close to your child?

Selected Value: 1

12. Go to a crowded store or mall with your child. When you are standing behind the child and he or she is looking at something, ask a question. How difficult does it seem to be for your child to hear and understand what you say?

Selected Value: 1

13. Go into a large room with your child and speak to him or her from across the room. How well does he or she seem to hear and understand what you say?

Selected Value: 1

14. Travel in the car with your child in the backseat. From the front seat say something to your child or ask a question. How easy does it seem for him or her to hear and understand what is said in the car?

Selected Value: 1

15. Sit in a quiet place, face your child and have a conversation or ask questions. How difficult does it seem for him or her to hear and understand what you say?

Selected Value: 1

8. GREAT
Hear every word, understand everything

7. GOOD
Hear it all, miss part of an occasional word, still understand everything

6. PRETTY GOOD
Hear almost all of the words and usually understand everything

5. OKAY BUT NOT EASY
Hear almost all the words, sometimes misunderstand what was said

4. IT TAKES WORK BUT USUALLY CAN GET IT
Hear most of the words, understand more than half of what was said

3. SOMETIMES GET IT, SOMETIMES DON’T
Hear words but understand less than half of what was said

2. TOUGH GOING
Sometimes don’t know right away that someone is talking, miss most of message

1. HUH?
Don’t know that someone is talking, miss all of message