SENSORY LEARNING SUMMARY (SLS)

SECTION 1 - PROCEDURES

Use information from the team of learning partners, medical reports, and current assessments to complete Part I: Medical Needs and Part II: Sensory Functioning Needs.

SECTION 2 - BACKGROUND INFORMATION

  1. Learner:
  2. Date of Birth:
  3. Summary Completed by:
  4. Date:

SECTION 3 - PART I: MEDICAL NEEDS

  1. Medical Conditions:
  2. Source of Information:
  3. Current Medications:
  4. Allergies to Medications:
  5. Source of Information:
  6. Issues
  7. Nutritional:
  8. Source of Information:
  9. Hydration:
  10. Source of Information:
  11. Elimination:
  12. Source of Information:
  13. Respiration:
  14. Source of Information:
  15. Sleep:
  16. Source of Information:
  17. Seizure:
  18. Source of Information:
  19. Allergy:
  20. Source of Information:
  21. Other:
  22. Source of Information:

SECTION 4 - PART II: SENSORY FUNCTIONING NEEDS

VISION:

  1. Source of Information:
  1. If the learner has a documented vision loss, describe the following:
  2. Medical Diagnosis:
  3. Corrective Lenses/Visual Aides:
  4. Medications:
  5. Therapies:
  6. Has a vision specialist recommended modifications? If so, describe.
  7. Lighting:
  8. Contrast:
  9. Size:
  10. Clutter:
  11. Distance:
  12. Color:
  13. Field:
  14. Right –
  15. Left –
  16. Mid –
  17. Top –
  18. Bottom –
  19. Other:
  20. Are there specific cautions for the presentation of visual stimuli?
  21. Are there specific positioning needs related to visual attendance?

6.HEARING:

  1. Source of Information:
  1. If the learner has a documented hearing loss, describe the following:
  2. Medical Diagnosis:
  3. Hearing aids or other sound amplification devices:
  4. History of ear infections:
  5. Medications:
  6. Tubes:
  7. Has a hearing specialist recommended specific modifications?:
  8. Presentation distance:
  9. Clutter:
  10. Frequency:
  11. High –
  12. Mid –
  13. Low –
  14. Loudness
  15. Are there specific cautions for the presentation of auditory stimuli?
  16. Are there specific positioning needs related to auditory attending?

11.TOUCH:

  1. Source of Information:
  1. If there is an impairment that restricts tactual exploration of the environment, describe below.
  2. Medical Diagnosis:
  3. Orthopedic or congenital abnormalities related to touch.
  4. Medications:
  5. Therapies:
  6. Devices/equipment:
  7. Helpful:
  8. Not Helpful:
  9. Specific recommendations:
  10. If the learner avoids or responds negatively to touch input, describe the stimulus and response.
  11. Light touch
  12. Deep touch
  13. Has an occupational or physical therapist determined that the learner is tactually defensive?
  14. Is the learner currently receiving sensory integration therapy?
  15. Have specific modifications for tactual input been recommended? Describe below.
  16. Type
  17. Receptivity
  18. Pacing
  19. Pressure
  20. Texture
  21. Temperature
  22. Other
  23. Are there specific cautions for the presentation of tactual stimuli?
  24. Are there positioning needs related to tactual attendance?
  25. VESTIBULAR/PROPRIOCEPTIVE
  26. Source of Information
  27. If the learner has documented movement disorders, describe them below.
  28. Medical source
  29. Medications
  30. If the learner becomes fussy, agitated, or withdrawn when moved, describe the typlical conditions that trigger these behaviors.
  31. Are there specific cautions for moving the learner?
  32. Are modifications needed related to movement of the learner?
  33. Speed
  34. Direction/angle
  35. Duration
  36. GUSTATORY
  37. Source of Information
  38. Are there any cautions for the presentation of gustratory stimuli?
  39. Are there any positioning needs related to gustatory stimulation?
  40. Are there allergy issues related to gustatory stimulation?
  41. OLFACTORY
  42. Source of Information
  43. Are there any cautions for the presentation of olfactory stimuli?

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