Child’s Name:____________________ Date of Birth:_________Date:______

Tactile

__ Dislikes standing in line

__ Bothered by tags on shirts

__ Dislikes playing in messy things

__ Reacts aversively to textured foods

__ Likes only highly textured foods

__ Does not react to falls, scrapes or bumps

__ Touches everything - walks touching the wall

__ Constantly puts things in mouth

Proprioceptive

__ Stamps feet or bangs with hands

__ Writes or holds pencil too hard (or too soft)

__ Plays too roughly

__ Seems unaware of body in space – clumsy

__ Handles toys roughly – lots of banging and breaking

__ Deliberately falls or tumbles a lot

__ Chews hard on things

__ Poor motor planning in gross/fine motor skills

Vestibular

__ Wiggles around during seated activities

__ Craves spinning or swinging

__ Rocks while seated or standing

__ Likes being upside down

__ Constantly in motion

__ Is afraid of movement

__ Experiences car sickness

__ Avoids playground equipment

__ Fears having head tilted backward (i.e. Hair washing)

__ Is afraid to sit on a toilet

Auditory

__ Covers ears or screams w/ sudden loud noises (i.e. vacuum, toilet flushing)

__ Difficulty locating sound

__ Enjoys constantly making sounds (i.e. humming)

__ Constantly distracted by background sounds (i.e. fluorescent lights hum)

__ Prefers music very loud

Vision

__ Demonstrates poor eye contact

__ Turns head to the side when looking at things

__ Holds head very close to work

__ Loses place on page when reading

__ Difficulty copying from the board

__ Uses hand as a “visor” when in bright sunlight or fluorescent lighting

__ Difficulty tracking a ball to catch

Arousal & Attending

__ Is hyperactive and difficult to calm

__ Has difficulty modulating emotional response

__ Startles easily

__ Difficult to arouse and does not react to loud sounds, bright lights etc.

__ Has difficulty completing tasks

__ Difficulty transitioning from one task to another

Social Consciousness

__ Reacts with laughter when someone expresses anger, sadness, fear

__ Becomes fearful in social situations

__ Does not spontaneously interact in a group

__ Appears to be unaware of others feelings

__ Cannot identify happy/sad/angry faces

Olfactory/Gustatory

__ Complains of things “smelling bad”

__ Notices how people smell

__ Reacts violently to smells

__ Smells objects constantly

__ Prefers foods that are highly spiced or bland

__ Chooses very limited repertoire of foods (i.e. prefers smooth vs. texture)