Student Questionnaire for Speech and Language Difficulties

The aim of this questionnaire is to gather information about children with speech and language difficulties in order to understand their needs.
Part 1: Students Background

Name: ___________________________ DOB: ______ Age: ______

1. How many sibling do you have? _________________________ 2. You are number ____________ in your family. 3. What is your father name? _____________________________ 4. What is your mother name? ____________________________ 5. What is your father occupation? ________________________ 6. What is your mother occupation? ________________________ 7. Do you have any problem in speech? YES NO 8. When do you realize you have problem in speech? 0-3 Years Old 4-5 Years Old 6-8 Years Old 9-12 Years Old

9. Are there people in your family that have speech difficulties? Relationship FATHER / MOTHER (PARENTS) BROTHER / SISTER (SIBLING) Speech Difficulty ________________________________________ ________________________________________

PART 2 (Background of Speech Problem) (Please check) ( / ) Articulation Impairment 1. Do you have problem in pronunciation or difficulty making particular sounds. Try Read; House, Horses, Harsh Often Always Sometimes Rarely 2. Do you find people having trouble to understand your speech? Often Always Sometimes Rarely

Fluency disorder 3. Do you have problem in making sentences when speaking? (fluency disorder) Often Always Sometimes Rarely 4. Do you repeat words when speaking? Often Always Sometimes Rarely

Voice Disorder 5. Do you have problem in controlling your voice when speaking? Often Always Sometimes Rarely 6. Did you ever feel like losing words when speaking with someone? Often Always Sometimes Rarely Language Disorder 7. Did you ever have problem in expressing ideas, needs, information or feeling? Often Always Sometimes Rarely 8. Did you have problem in understanding what other people said? Often Always Sometimes Rarely 9. Do you having problem in selecting appropriate word or vocabulary to construct sentence? Often Always Sometimes Rarely 10. Can you follow instruction and direction appropriately? Often Always Sometimes Rarely

11. Can you pronounce words with more than two syllables? Often Always Sometimes Rarely 12. How do you find attending language classes? Exciting Fun Bored Hard 13. How do you feel when taking oral test? Easy Moderate Hard 14. Can you complete your oral task on time? Often Always Sometimes Rarely

PART 2 (Types of disfluencies) This part is carry out by the interviewer, ask them the sample question provided below and check if the student have certain speech problem. (Please check) Seldom Or Not Observed ______ Sometimes Often

a. Hesitations Pauses as if thinking about what to say before or during speaking. Q: Where do you live? Q: What is your pets name?

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b. Phase Repetitions (Mom,, can I, can I, get some candy?/ My hobby is, is, to play, to play..) Q: What is your hobby?

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d. Sound repetitions, especially uh/Aaa. (M, m, m, mom, can I go? or Uh, uh, Can I, uh, go, uh, uh, home?) Q: Do you like drawing? Q: Can you draw me a picture? e. Prolongations Stretching or holding into a sound (Mmmmmmom, I want it.) Q: Do you like present? Q: What do you want for your birthday? g. Non-speech behaviors. (Blink eyes, slap body, bend or move body in some way to get speech started)

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PART 3 (Special Needs) How do you feel when you speak, With a family member? Relaxed Comfortable Anxious Annoyed Fearful

With close friend? Relaxed Comfortable Anxious Annoyed Fearful With teacher/strangers (one-to-one conversation)? Relaxed Comfortable Anxious Annoyed Fearful

To a group of people/ whole class? Relaxed Comfortable Anxious Annoyed Fearful Do you think you need help to improve your speech? YES NO

END OF QUESTIONAIRE