Buffalo Model Questionnaire
Answer the yes/no items and add your name and dates as requested.
Respondent Information
First Name
*
Last Name
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
DOB
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service History
Service history and years received
*
Rows
Currently receiving
Has received
Number of years
Auditory training
1
2
Speech therapy
3
4
Phonological awareness
5
6
Special phonics training
7
8
Special help with reading
9
10
Sensory-integration training
11
12
Auditory training currently receiving?
Yes
No
Auditory training has received?
Yes
No
Auditory training number of years
Speech therapy currently receiving?
Yes
No
Speech therapy has received?
Yes
No
I have a problem saying speech sounds
*
Yes
No
I have a problem understanding language
*
Yes
No
I have a problem understanding spoken instructions
*
Yes
No
I have a problem reading aloud
*
Yes
No
I have a problem with phonics
*
Yes
No
I have a problem with spelling
*
Yes
No
I respond slowly or delayed to spoken language
*
Yes
No
I may have a problem learning a foreign language
*
Yes
No
I speak slowly
*
Yes
No
I am hypersensitive to noise
*
Yes
No
I am distracted by noise
*
Yes
No
I struggle to understand speech in noise
*
Yes
No
I make more noises than my peers
*
Yes
No
I respond too quickly, at times
*
Yes
No
I interrupt others frequently while they are talking
*
Yes
No
I have a problem with reading comprehension
*
Yes
No
I speak quickly
*
Yes
No
I forget things I have been told
*
Yes
No
I have a problem remembering spoken instructions
*
Yes
No
I have a problem paying attention
*
Yes
No
I have a problem using language
*
Yes
No
I may have ADHD/ADD
*
Yes
No
I have anxiety (e.g., new situations)
*
Yes
No
Submit
Should be Empty: