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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