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SENSORYMOTOR HISTORY QUESTIONNAIRE FOR

CHILDREN AND ADOLESCENTS

Child’s Name: Date:

Name of person completing form:

Relationship to child:

Please circle either Y (Yes) or N (No) to answer the questions below.

I. VISUAL FUNCTIONING

1. Skips words or lines when reading Y N

2. Rereads lines or phrases Y N

3. Reads slowly Y N

4. Uses finger or other marker to keep place Y N

5. Usually reads aloud or moves lips when reading to self Y N

6. Reverses letters, numbers or words Y N

7. Has difficulty remembering what is read Y N

8. Becomes tired or restless after a period of visual concentration Y N

9. Complains of letters or lines running together or jumping around Y N

10. Complains of blurred vision while reading or writing Y N

11. Comprehension worse over time, or loses interest quickly Y N

12. Blinks excessively Y N

13. Frowns, scowls or squints when reading Y N

14. Holds reading materials closer than normal Y N

15. Moves head while reading Y N

16. Covers or closes one eye while reading Y N

17. Avoids close work Y N

18. Tilts head to one side while reading Y N

19. Rubs eyes frequently Y N

20. Rests head on arm when writing Y N

21. Awkward posture while reading or writing Y N

22. Often confuses similar words Y N

23. Poor eye-hand coordination Y N

24. Clumsy, bumps into things Y N

25. Thrusts head forward or backward while looking in distance Y N

26. One eye turns in or out Y N

27. Excessive tearing of eyes Y N

28. Frequent styes Y N

29. Eyes or eyelids often red Y N

30. Headaches in forehead or temple when reading Y N

31. Repeatedly omits small words when reading aloud Y N

32. Writes up or downhill on paper Y N

33. Complains of seeing double Y N

34. Repeatedly confuses left and right Y N

35. Misreads words that have similar beginning letters or sounds Y N

36. Confuses similarities and minor differences in words Y N

37. Makes errors when copying from book or blackboard Y N

38. Large pupils in normal light. Y N

39. Excessive squinting from bright light. Y N

40. Writing is crooked or poorly spaced. Y N

41. Appears sensitive to light, preferring dark or dim lighting. Y N

42. Has difficulty discriminating shapes or colors. Y N

43. Has difficulty keeping eyes focused on objects. Y N

44. Cannot follow a moving object or line of print smoothly. Y N

45. Becomes excited with a lot of visual stimuli. Y N

46. Resists having vision blocked. Y N

47. Has difficulty with written instructions. Y N

48. Math homework is messy. Y N

II. AUDITORY PROCESSING (Fisher’s Auditory Problems Checklist)

1. Has a history of hearing loss Y N

2. Has a history of ear infections Y N

3. Does not listen to instructions 50% or more of the time Y N

4. Has difficulty following verbal directions, must repeat often Y N

5. Does not learn well by listening Y N

6. Cannot always relate what is heard to what is seen Y N

7. Cannot attend to auditory stimuli for more than a few seconds Y N

8. Frequently misunderstands what is said Y N

9. Says, “Huh?” or “What?” at least five or more times daily Y N

10. Forgets what is said within a few minutes Y N

11. Has a short attention span Y N

12. Daydreams, attention drifts, seems out of it at times Y N

13. Easily distracted by background noise Y N

14. Experiences problems with sound discrimination Y N

15. Startles easily to sudden or loud sounds Y N

16. Notices sounds before others do Y N

17. Gives unusual descriptions of sounds Y N

18. Constant humming or audible self-talk Y N

19. Needs frequent quiet time to regain energy and focus Y N

20. Does not understand many words or ideas appropriate for age Y N

21. Has a problem speaking or writing Y N

22. Has an articulation problem Y N

23. Below average performance in at least one subject area Y N

24. Is concerned may have autism, dyslexia, or ADHD Y N

25. Is very sensitive to background sounds. Y N

26. Often shouts or speaks in a loud voice. Y N

27. Frequently makes repetitive noises or sounds. Y N

28. Fails to follow through on verbal requests. Y N

29. Confuses spoken words that sound similar. Y N

III. TACTILE (Touch)

1. Overreacts to physically painful experiences. Y N

2. Under-reacts to physically painful experiences. Y N

3. Avoids messy activities. Y N

4. Craves messy activities. Y N

5. Dislikes being touched, especially unexpectedly. Y N

6. Craves being touched. Y N

7. Seeks out physically aggressive contact Y N

8. Is excessively ticklish. Y N

9. Avoids using hands for prolonged periods of time. Y N

10. Complains cannot feel sensation in some part of body Y N

11. Seems to learn best “hands on” Y N

IV. BALANCE AND MOVEMENT (Vestibular/Proprioceptive)

1. Has poor balance Y N

2. Has difficulty going up and down stairs or hills. Y N

3. Often rocks in chair or assumes an upside-down position. Y N

4. Often props head in hands while reading or writing. Y N

5. Seems fearful in space (like on swings, heights, or see-saw) Y N

6. Is afraid of or avoids fast-moving activities on playground Y N

7. Seems sensitive to movement, becoming dizzy or nauseous. Y N

8. Prefers fast-moving or spinning activities. Y N

V. COORDINATION

1. Has difficulty with manual skills and/or handwriting. Y N

2. Seems clumsy and accident-prone, often trips or falls. Y N

3. Has difficulty learning new movement activities. Y N

4. Was slow to show a clear hand preference. Y N

5. Must be reminded to hold paper while writing. Y N

VI. MUSCLE TONE

1. Appears stiff and rigid. Y N

2. Appears loose and floppy. Y N

3. Has poor standing and/or sitting posture. Y N

4. Grasps objects too tightly. Y N

5. Grasps objects too loosely. Y N

6. Tires easily. Y N

VII. SMELL (Olfactory)

1. Is overly sensitive to certain smells. Y N

2. Ignores noxious odors. Y N

3. Has difficulty discriminating odors. Y N