Background Information and Occupational Intake

In order to help us provide the best possible services to you and your child, please complete the following information.


    Family Information

    Referring Information

    School History

    School Name and Teacher:


    RightLeftBoth


    YesNo


    OTPTSpeech and Language

    Medical History


    YesNo


    VaginalCesareanBreech


    YesNo


    YesNo


    PsychologistPTSpeech and LanguageNutritionistBehavioral SpecialistOther:

    Developmental History


    RollingSitting aloneCreeping on all 4sPull to standWalkingFirst wordCombined words (2 or more words)Finger feedingEating with a spoon/fork (circle utensil if only one)Cutting with a knifeUsing scissorsJumpingRiding a bike


    within typical age rangesdelayed

    Please check the amount of assistance needed for your child/patient to complete the following:


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)


    Independent (completes without help)I assist 50% or moreDependent (total assistance needed)

    Describe your child/patient at present:


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes


    YesNoSometimes

    Social and Occupational History

    Does your child/patient:


    OftenSometimesRarely


    OftenSometimesRarely


    OftenSometimesRarely


    OftenSometimesRarely


    OftenSometimesRarely


    OftenSometimesRarely

    In the community, does your child/patient?


    OftenSometimesRarely


    OftenSometimesRarely


    OftenSometimesRarely


    OftenSometimesRarely

    Sensory Processing Checklist

    The purpose of this sensory processing checklist is to help you the parent/caregiver become educated about particular signs of sensory processing dysfunction and allows the professional to gather a background of behavior responses. It is not to be used as a diagnostic criteria for labeling children with sensory processing disorder; but rather, as an educational tool and checklist for knowledge. Please check symptoms that you feel best describe your child’s/patient’s sensory behaviors.

    Tactile Sense: input from the skin receptors about touch, pressure, temperature, pain, and movement of the hairs on the skin.

    Signs of Tactile Dysfunction:


    becomes fearful, anxious or aggressive with light or unexpected touchas an infant, did/does not like to be held or cuddled; may arch back, cry, and pull awayappears fearful of, or avoids standing in close proximity to other people or peers (especially in lines)becomes frightened when touched from behind or by someone/something they cannot see (such as under a blanket)complains about having hair brushed; may be very picky about using a particular brushavoids group situations for fear of the unexpected touchresists friendly or affectionate touch from anyone besides parents or siblingsdislikes kisses, will 'wipe off' place where kissedprefers hugsa raindrop, water from the shower, or wind blowing on the skin may feel like torture and produce adverse and avoidance reactionsmay overreact to minor cuts, scrapes, and or bug bitesavoids touching certain textures of material (blankets, rugs, stuffed animals)refuses to wear new or stiff clothes, clothes with rough textures, turtlenecks, jeans, hats, or belts, etc.avoids using hands for playavoids/dislikes/aversive to 'messy play', i.e., sand, mud, water, glue, glitter, PlayDoh, slime, shaving cream/funny foam etc.will be distressed by dirty hands and want to wipe or wash them frequentlydistressed by seams in socks and may refuse to wear themdistressed by clothes rubbing on skin; may want to wear shorts and short sleeves year round, toddlers may prefer to be naked and pull diapers and clothes off constantlyor, may want to wear long sleeve shirts and long pants year round to avoid having skin exposeddistressed about tags in clothing, may ask to have removeddistressed about having face washeddistressed about having hair, toenails, or fingernails cutresists brushing teeth and is extremely fearful of the dentistis a picky eater, only eating certain tastes and textures; mixed textures tend to be avoided as well as hot or cold foods; resists trying new foodsmay refuse to walk barefoot on grass or sandmay walk on toes only


    may crave touch, needs to touch everything and everyoneis not aware of being touched/bumped unless done with extreme force or intensityis not bothered by injuries, like cuts and bruises, and shows no distress with shots (may even say they love getting shots!)may not be aware that hands or face are dirty or feel his/her nose runningmay be self-abusive; pinching, biting, or banging his own headmouths objects excessivelyfrequently hurts other children or pets while playingrepeatedly touches surfaces or objects that are soothing (i.e., blanket)seeks out surfaces and textures that provide strong tactile feedbackthoroughly enjoys and seeks out messy playcraves vibrating or strong sensory inputhas a preference and craving for excessively spicy, sweet, sour, or salty foods


    has difficulty with fine motor tasks such as buttoning, zipping, and fastening clothesmay not be able to identify which part of their body was touched if they were not lookingmay be a messy dresser; looks disheveled, does not notice pants are twisted, shirt is half untucked, shoes are untied, one pant leg is up and one is down, etc.has difficulty using scissors, crayons, or silverwarecontinues to mouth objects to explore them even after age twohas difficulty figuring out physical characteristics of objects; shape, size, texture, temperature, weight, etc.may not be able to identify objects by feel, uses vision to help; such as, reaching into backpack or desk to retrieve an item

    Vestibular Sense: The vestibular system is the sensory system that responds to motion or change of head position. The receptors for movement are located in the inner ear. They tell the brain what direction the head is moving, the speed of the movement and where we are in space.


    avoids/dislikes playground equipment; i.e., swings, ladders, slides, or merry-go-roundsprefers sedentary tasks, moves slowly and cautiously, avoids taking risksavoids/dislikes elevators and escalators; may prefer sitting while they are on them or, actually get motion sickness from themmay appear terrified of falling even when there is no real risk of itafraid of heights, even the height of a curb or stepfearful of feet leaving the groundfearful of going up or down stairs or walking on uneven surfacesafraid of being tipped upside down, sideways or backwards; will strongly resist getting hair washed over the sinkstartles if someone else moves them; i.e., pushing his/her chair closer to the tableas an infant, may never have liked baby swings or jumpersmay be fearful of, and have difficulty riding a bike, jumping, hopping, or balancing on one foot (especially if eyes are closed)may have disliked being placed on stomach as an infantloses balance easily and may appear clumsyavoids rapid or rotating movements


    in constant motion, can't seem to sit stillcraves fast, spinning, and/or intense movement experiencesloves being tossed in the aircould spin for hours and never appear to be dizzyloves the fast, intense, and/or ‘scary’ rides at amusement parksalways jumping on furniture, trampolines, spinning in a swivel chair, or getting into upside down positionsloves to swing as high as possible and for long periods of timeis a 'thrill-seeker'; dangerous at timesalways running, jumping, hopping etc. instead of walkingrocks body, shakes leg, or head while sitting


    'floppy' body'frequently slumps, lies down, and/or leans head on hand or arm while working at his/her deskdifficulty simultaneously lifting head, arms, and legs off the floor while lying on stomach ('superman' position)often sits in a 'W sit' position on the floorfatigues easily!compensates for 'looseness' by grasping objects tightlydifficulty turning door knobs, handles, opening and closing itemsdifficulty catching him/her self if fallingdifficulty getting dressed and doing fasteners, zippers, and buttonsmay have never crawled or limited period of time when did crawl as a babyhas poor body awareness; bumps into things, knocks things over, trips, and/or appears clumsypoor gross motor skills; jumping, catching a ball, jumping jacks, climbing a ladder, etc.poor fine motor skills; difficulty using 'tools', such as pencils, silverware, combs, scissors etc.may appear ambidextrous, frequently switching hands for coloring, cutting, writing etc.; does not have an established hand preference/dominance by 4 or 5 years oldseems to be unsure about how to move the body during movement, for example, stepping over something

    Proprioceptive Sense: input from the muscles and joints about body position, weight, pressure, stretch, movement, and changes in position in space.

    Signs Of Proprioceptive Dysfunction:


    seeks out jumping, bumping, and crashing activitiesstomps feet when walkingkicks his/her feet on the floor or chair while sitting at a desk/tableloves to be tightly wrapped in many or weighted blankets, especially at bedtimeprefers clothes (and belts, hoods, shoelaces) to be as tight as possibleloves/seeks out 'squishing' activities, enjoys bear hugsexcessive banging on/with toys and objectsloves 'rough-housing' and tackling/wrestling gamesfrequently falls on floor intentionallywould jump on a trampoline for hours on endgrinds his/her teeth throughout the dayloves pushing/pulling/dragging objectsloves jumping off furniture or from high placesfrequently hits, bumps or pushes other childrenchews on pens, straws, shirt sleeves etc.


    difficulty regulating pressure when writing/drawing; may be too light to see or so hard the tip of writing utensil breakswritten work is messy and he/she often rips the paper when erasingalways seems to be breaking objects and toysmisjudges the weight of an object, such as a glass of juice, picking it up with too much force sending it flying or spilling, or with too little force and complaining about objects being too heavymay not understand the idea of 'heavy' or 'light'; would not be able to hold two objects and tell you which weighs moreseems to do everything with too much force; i.e., walking, slamming doors, pressing things too hard, slamming objects downplays with animals with too much force, often hurting them

    Signs Of Auditory Dysfunction: (no diagnosed hearing problem)


    distracted by sounds not normally noticed by others; i.e., humming of lights or refrigerators, fans, heaters, or clocks tickingfearful of the sound of a flushing toilet (especially in public bathrooms), vacuum, hairdryer, squeaky shoes, or a dog barkingstarted with or distracted by loud or unexpected soundsbothered/distracted by background environmental sounds; i.e., lawn mowing or outside constructionfrequently asks people to be quiet; i.e., stop making noise, talking, or singingruns away, cries, and/or covers ears with loud or unexpected soundsmay refuse to go to movie theaters, parades, skating rinks, musical concerts, firework show etc.


    often does not respond to verbal cues or to name being calledappears to 'make noise for noise's sake'loves excessively loud music or TVseems to have difficulty understanding or remembering what was saidappears oblivious to certain soundsappears confused about where a sound is coming fromtalks self through a task, often out loudneeds directions repeated often, or will say, / What?' frequently'

    Signs Of Oral Input



    may lick, taste, or chew on inedible objectsprefers foods with intense flavor; i.e., excessively spicy, sweet, sour, or saltyexcessive drooling past the teething stagefrequently chews on hair, shirt, or fingersconstantly putting objects in mouth past the toddler yearsacts as if all foods taste the samecan never get enough condiments or seasonings on his/her foodloves vibrating toothbrushes and even trips to the dentist

    Signs Of Olfactory Dysfunction (Smells):


    reacts negatively to, or dislikes smells which do not usually bother, or get noticed by other peopletells other people (or talks about) how bad or funny they smellrefuses to eat certain foods because of their smelloffended and/or nauseated by bathroom odors or personal hygiene smellsbothered/irritated by the smell of perfume or colognebothered by household or cooking smells


    has difficulty discriminating unpleasant odorsmay drink or eat things that are poisonous because they do not notice the noxious smellunable to identify smells from scratch 'n sniff stickersdoes not notice odors that others usually complain aboutfails to notice or ignores unpleasant odorsmakes excessive use of smelling when introduced to objects, people, or places

    Signs Of Visual Input Dysfunction (No Diagnosed Visual Deficit):


    sensitive to bright lights; will squint, cover eyes, cry and/or get headaches from the lighthas difficulty keeping eyes focused on task/activity he/she is working on for an appropriate amount of timeeasily distracted by other visual stimuli in the room; i.e., movement, decorations, toys, windows, doorways etc.has difficulty in bright colorful rooms or a dimly lit roomrubs his/her eyes, has watery eyes or gets headaches after reading or watching TVavoids eye contact


    has difficulty telling the difference between similar printed letters or figures; i.e., p & q, b & d,+ and x, or square and rectanglehas a hard time seeing the 'big picture'; i.e., focuses on the details or patterns within the picturehas difficulty locating items among other items; i.e., papers on a desk, clothes in a drawer, items on a grocery shelf, or toys in a bin/toy boxoften loses place when copying from a book or the chalkboarddifficulty controlling eye movement to track and follow moving objectshas difficulty telling the difference between different colors, shapes, and sizesoften loses his/her place while reading or doing math problemsmakes reversals in words or letters when copying, or reads words backwards; i.e., 'was' for 'saw and 'no' for 'on' after first gradecomplains about 'seeing double'difficulties finding differences in pictures, words, symbols, or objectsdifficulty with consistent spacing and size of letters during writing and/or lining up numbers in math problemsdifficulty with jigsaw puzzles, copying shapes, and/or cutting/tracing along a linetends to write at a slant (up or down hill) on a pageconfuses left and rightfatigues easily with schoolworkdifficulty judging spatial relationships in the environment; i.e., bumps into objects/people or missteps on curbs and stairs


    unable to locate the source of a sounddifficulty identifying people's voicesdifficulty discriminating between sounds/words; i.e., 'dare' and 'dear'difficulty filtering out other sounds while trying to pay attention to one person talkingbothered by loud, sudden, metallic, or high-pitched soundsdifficulty attending to, understanding, and remembering what is said or read; often asks for directions to be repeated and may only be able to understand or follow two sequential directions at a timelooks at others to/for reassurance before answeringdifficulty putting ideas into words (written or verbal)often talks out of turn or 'off topic'if not understood, has difficulty re-phrasing; may get frustrated, angry, and give updifficulty reading, especially out loud (may also be dyslexic)difficulty articulating and speaking clearlyability to speak often improves after intense movement

    Emotional Response, Play, And Self-Regulation Dysfunction:


    difficulty accepting changes in routine (to the point of tantrums)gets easily frustratedoften impulsivefunctions best in small group or individuallyvariable and quickly changing moods; prone to outbursts and tantrumsprefers to play on the outside, away from groups, or just be an observeravoids eye contactdifficulty appropriately making needs known


    difficulty with imitative play (over 10 months)wanders aimlessly without purposeful play or exploration (over 15 months)needs adult guidance to play, difficulty playing independently (over 18 months)participates in repetitive play for hours; i.e., lining up toy cars, blocks, watching one movie over and over etc.


    excessive irritability, fussiness or colic as an infantcan't calm or soothe self through pacifier, comfort object, or caregivercan't go from sleeping to awake without distressrequires excessive help from caregiver to fall asleep; i.e., rubbing back or head, rocking, long walks, or car rides


    severe/several mood swings throughout the day (angry to happy in short periods of time, perhaps without visible cause)unpredictable state of arousal or inability to control arousal level (hyper to lethargic, quickly, vacillating between the two; over stimulated to under stimulated, within hours or days, depending on the activity and setting, etc.)frequent constipation or diarrhea, or mixed during the same day or over a few daysdifficulty with potty training; does not seem to know when he/she has to go (i.e., cannot feel the necessary sensation that bowel or bladder are fullunable to regulate hunger; eats all the time, won't eat at all, unable to feel full/hungry

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