Answer Each Question, Indicating Which of These Behaviors Your Child Exhibits

Child’s Name: ______

SENSORY HISTORY

Answer each question, indicating which of these behaviors your child exhibits.

TOUCH

Does your child:

dislike getting his/her hands messy or touching unfamiliar things?YesNoSometimes

dislike having his/her hair brushed, cut, or washed?YesNoSometimes

become irritated by the feel of certain clothing or tags in clothing?YesNoSometimes

become irritable when held?YesNoSometimes

prefer rough, firm hugs?YesNoSometimes

like to be tickled?YesNoSometimes

dislike being barefoot?YesNoSometimes

enjoy baths?YesNoSometimes

seem unaware of being hurt, injured, or bruised?YesNoSometimes

object to being hugged or touched by unfamiliar people?YesNoSometimes

prefer to initiate his/her own greetings, hugs, and hand holding?YesNoSometimes

seem upset at large family gatherings?YesNoSometimes

avoid being in the center of a group of other children?YesNoSometimes

react with hitting or pushing when other children get too close?YesNoSometimes

bump and push during play?YesNoSometimes

frequently walk on her/his toes?YesNoSometimes

like to play in sand?YesNoSometimes

play roughly with toys?YesNoSometimes

become upset going to the supermarket or shopping mall?YesNoSometimes

MOVEMENT

Does your child:

enjoy rough house play?YesNoSometimes

has he/she ever intentionally banged his/her head?YesNoSometimes

enjoy repeatedly jumping on beds, sofas, or the floor?YesNoSometimes

ever tense and quickly move his hands when excited?YesNoSometimes

hit or throw objects when frustrated?YesNoSometimes

seem to throw herself/himself into furniture or people when running?YesNoSometimes

like McDonald Play Place?YesNoSometimes

VESTIBULAR

Does your child:

like to rock?YesNoSometimes

like to be tipped upside down?YesNoSometimes

seek to play on playground equipment?YesNoSometimes

seem fearful of playground equipment?YesNoSometimes

enjoy repeated bouncing, swinging, spinning, or twirling?YesNoSometimes

seem fearful of swinging?YesNoSometimes

get upset when picked up or moved unexpectedly?YesNoSometimes

COORDINATION

Does your child:

appear more clumsy than other children?YesNoSometimes

seem to be a messy eater?YesNoSometimes

frequently fall, trip, or bump into things during play?YesNoSometimes

appear to be interested in dressing or undressing herself/himself?YesNoSometimes

prefer active play to table top activities?YesNoSometimes

have difficulty learning new motor tasks?YesNoSometimes

ORAL

Does your child:

like having her/his face washed or wiped?YesNoSometimes

put toys or other objects in his mouth?YesNoSometimes

has difficulty eating solid foods?YesNoSometimes

bites objects or people?YesNoSometimes

reject certain tastes or textures of food?YesNoSometimes

seem to be a picky eater?YesNoSometimes

reject having his teeth brushed?YesNoSometimes

like to eat frequently throughout the day rather than at meals?YesNoSometimes

AUDITORY

Does your child:

ever repeat the same sounds over and over when excited?YesNoSometimes

seem to be sensitive to loud or unexpected noises?YesNoSometimes

seem oversensitive to familiar sounds?YesNoSometimes

seem unaware of sound or people talking to her/him?YesNoSometimes

prefer toys which play music or make sounds?YesNoSometimes

dislike being sung to?YesNoSometimes

like having stories read to her/him?YesNoSometimes

like to repeatedly make funny noises?YesNoSometimes

repeat words or phrases, heard in the past but unrelated to current environment?YesNoSometimes

listen to you when you talk to him?YesNoSometimes

seem to be quiet?YesNoSometimes

VISUAL

Does your child:

avoid eye contact?YesNoSometimes

look away when over-stimulated?YesNoSometimes

prefer to watch familiar video tapes or TV shows to other activities?YesNoSometimes

like to line up or sort toys?YesNoSometimes

avoid playing when too many objects are in front of him?YesNoSometimes

like looking at books with busy pictures?YesNoSometimes

seem to be sensitive to the sun or bright lights?YesNoSometimes

ACTIVITY

Does your child:

sleep a lot?YesNoSometimes

sleep poorly and/or wake frequently?YesNoSometimes

prefer to play by himself?YesNoSometimes

seem passive or less active than other children his age?YesNoSometimes

fatigue easily?YesNoSometimes

did your child rarely cry as a baby?Yes No Sometimes

were your child’s motor milestones delayed?YesNoSometimes

SOCIAL

Does your child:

easily become frustrated?YesNoSometimes

have difficulty handling new situations?YesNo Sometimes

have difficulty changing from one activity to another?YesNoSometimes

seem impulsive?YesNoSometimes

accept changes in his routine?YesNoSometimes

ADDITIONAL COMMENTS ON ANY OF YOUR ANSWERS