DEVELOPMENTAL/SENSORY HISTORY FORM
Patient’s Name: ______DOB:______Date:______
Parent #1Name:______Cell #:______
Parent #2 Name:______Cell #:______
CHILD’S BIRTH, INFANCY, TODDLER YEARS:
YesNoBrief Explanation
1) Premature______
2) Full term______
3) Required forceps______
4) Had any birth injuries______
5) Any major birth complications______
6) Had insufficient oxygen______
7) Any other problems after birth______
8) Did your child crawl______Age:______
9) What age did child walkAge:______
10) What age was child toilet trainedAge:______
11) When did your child begin putting clothes onAge:______
12) When did your child begin buttoning clothesAge:______
13) When did child begin tying shoesAge:______
GENERAL INFORMATION:
Which hand does your child prefer to use? ______
Was handedness ever changed: If so explain ______
______
What are your child’s special interests? ______
______
Give a brief thumbnail sketch of your child’s personality: ______
______
Has your child had a neurological, psychological or educational evaluation performed? If so by whom and the results: ______
______
School Name: ______Grade:______
YesNoBrief explanation
Attends school regularly______
Likes school______
Likes teacher______
Child is working to potential______
Ever repeated a grade______
Had special tutoring or remedial
work______
Changed schools often______
School seems overly stressful______
Loses place when reading______
Uses finger or marker______
Skips or omits words______
Rereads______
Reads out loud or lip reads______
Difficulty with comprehension______
Reverses letters or words______
Poor grades______
Poor handwriting______
Difficulty with spacing or sizing
of letters______
Difficulty with left and right______
Easiest subject______
Most difficult subject______
TACTILE DEVELOPMENT:
1) Child likes to be touched______
2) Dislikes being held or cuddled______
3) Prefers to touch rather than
be touched______
4) Excessively ticklish______
5) Easily irritated or enraged
when touched by others______
6) Has strong need to touch
objects or people ______
7) Avoids certain textures or food______
8) Objects to putting lotion on______
9) Picks fights frequently______
10) Pinches, bites, or hurts self
or others______
11) Bumps into or pushes others______
12) Bangs head on purpose______
13) Dislikes the feeling of certain
clothing______14) Overly sensitive to food or
water temperature______
YesNoBrief explanation
15) Prefers baths over showers______
16) Over or under dresses for the
temperature______
17) Does not like to play in water, sand, mud, etc ______
18) Lacks normal awareness of
being touched______
19) Often seems unaware of cuts,
bruises, etc.______
20) Examines objects with hands______
21) Mouths objects or toys
excessively______
VESTIBULAR:
1) Arches back when held or
moved______
2) Enjoys or likes being rocked______
3) Dislikes being tossed in air______
4) Dislikes fast spinning rides______
5) Dislikes to swing______
6) Spins or whirls more than
other children ______
7) Gets carsick easily______
8) Gets nauseous or vomits
from movement ______
9) Rocks while sitting______
10) Jumps around a great deal______
11) Has fear with stairs/heights______
12) Loses balance easily______
13) Walks on toes (not whole foot)______
COORDINATION:
1) Seems clumsy______
2) Bumps into objects______
3) Sat, stood or walked late______
4) Sat, stood or walked early______
5) Careless______
6) Frequently falls or trips______
7) Creeping/crawling stage was
omitted or very short______
8) Dislikes trying new movement
activities______
YesNoBrief explanation
9) Difficulty learning new
movement activities______
10) Has difficulty hopping, skipping
or running______
11) Difficulty with sequential tasks,
buttoning, zipping, tying______
12)Difficulty with rhythm or
alternating movements______
13)Avoids or has difficulty with
sports activities______
14)Difficulty with eye/hand
coordination______
15)Difficulty manipulating small
objects______
16)Difficulty with pencil/crayon
or cutting activities______
17) Has rigid movements______
18) Grimaces or uses tongue with
fine motor tasks______
MUSCLE TONE:
1) Feels heavier than looks______
2) Poor standing posture______
3) Poor sitting posture______
4) Seems weaker than normal______
5) Seems stronger than normal______
6) Grasp is either too tight/weak______
AUDITORY:
1) Has diagnosed hearing problem______
2) Has tubes in ears______
3) Frequent ear infections______
4) Seems too sensitive to sounds______
5) Responds to unexpected noise______
6) Fears particular sounds______
7) Distracted by sounds______
8) Misses some sounds or words______
9) Fails to listen or pay attention
to what is said______
10)Confused what direction
sounds come from______
11) Likes to make loud noises______
YesNoBrief explanation
12) Dislikes to sing or dance to
music______
BEHAVIOR:
1) Distractible______
2) Difficulty concentrating______
3) Difficulty completing a task______
4) Frequent daydreaming______
5) Feels inferior, poor confidence
and self image______
6) Depressed much of the time______
7) Particularly shy, timid, fearful______
8) Quite anxious, nervous or tense______
9) Emotionally dependent or
clinging______
10) Gets mad easily (aggressive)______
11) Frequent crying______
Please be more specific in answering these questions than above:
Child is overly sensitive to sensory experiences more so than most people:
Yes______No______If yes circle all that apply
Auditory (noises)
Tactile (clothing textures, food, temperatures)
Movement (playgrounds, amusement parks, swings, etc)
Comments: ______
Child doesn’t seem to react to sensory experiences like other people:
Yes______No______If yes circle all that apply
Auditory (noises)
Tactile (clothing textures, food, temperatures)
Movement (playgrounds, amusement parks, swings, etc)
Comments: ______
Child actively seeks out sensory experiences, more so than most people:
Yes______No______If yes circle all that apply
Auditory (noises)
Tactile (clothing textures, food, temperatures)
Movement (playgrounds, amusement parks, swings, etc)
Comments: ______
What are the presenting problems for your child currently?
Academic: ______
______
Sensory: ______
______
Motor: ______
______
Daily activities: (dressing, eating, playing): ______
______
Relationships: (difficulty playing with others, no friends, etc): ______
______
Thank you for carefully completing this questionnaire.
I give Hellerstein and Brenner Vision Center, P.C. authorization to send reports to the following:
Name:______
Address:______City:______Zip:______
Name:______
Address:______City:______Zip:______
Name:______
Address:______City:______Zip:______
Permission given by:
Your Name:______Date:______
I authorize Hellerstein and Brenner Vision Center to release and share information regarding my testing and or treatment program with the above listed professionals.