Developmental History
Please check all the developmental milestones that your child/patient achieved: Rolling Sitting alone Creeping on all 4s Pull to stand Walking First word Combined words (2 or more words) Finger feeding Eating with a spoon/fork (circle utensil if only one) Cutting with a knife Using scissors Jumping Riding a bike
First word Age:
Combined words (2 or more words): (age)
Developmental milestones were met: within typical age ranges delayed
Please check the amount of assistance needed for your child/patient to complete the following:
Takes off pants: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Puts on pants: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Takes off shirt: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Puts on shirt: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Buttons: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Zipper: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Snaps: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Puts on shoes: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Takes off shoes: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Ties shoes: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Puts on socks: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Takes off socks: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Toileting: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Bathing routine: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Tooth brushing: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Scooping with a spoon: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Spears with a fork: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Drinks from open cup: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Drinks from straw: Independent (completes without help) I assist 50% or more Dependent (total assistance needed)
Describe your child/patient at present:
Mostly quiet: Yes No Sometimes
Overly active: Yes No Sometimes
Tires easily: Yes No Sometimes
Talks constantly: Yes No Sometimes
Too impulsive: Yes No Sometimes
Restless: Yes No Sometimes
Stubborn: Yes No Sometimes
Resistant to change: Yes No Sometimes
Fights frequently: Yes No Sometimes
Usually happy: Yes No Sometimes
Exibits temper tantrums: Yes No Sometimes
Explain Temper Tantrums
Clumsy: Yes No Sometimes
Nervous ticks / habits: Yes No Sometimes
Wets bed: Yes No Sometimes
Wet bed frequency
Poor attention: Yes No Sometimes
Frustrated easily: Yes No Sometimes
Unusual fears: Yes No Sometimes
Unusual Fears List
Rocks self frequently: Yes No Sometimes
Difficulty falling asleep: Yes No Sometimes
Difficulty staying asleep: Yes No Sometimes
Sluggish in the mornings: Yes No Sometimes
Back Next
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:
Hypersensitivity To Touch (Tactile Defensiveness) becomes fearful, anxious or aggressive with light or unexpected touch as an infant, did/does not like to be held or cuddled; may arch back, cry, and pull away appears 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 brush avoids group situations for fear of the unexpected touch resists friendly or affectionate touch from anyone besides parents or siblings dislikes kisses, will 'wipe off' place where kissed prefers hugs a raindrop, water from the shower, or wind blowing on the skin may feel like torture and produce adverse and avoidance reactions may overreact to minor cuts, scrapes, and or bug bites avoids 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 play avoids/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 frequently distressed by seams in socks and may refuse to wear them distressed 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 constantly or, may want to wear long sleeve shirts and long pants year round to avoid having skin exposed distressed about tags in clothing, may ask to have removed distressed about having face washed distressed about having hair, toenails, or fingernails cut resists brushing teeth and is extremely fearful of the dentist is 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 foods may refuse to walk barefoot on grass or sand may walk on toes only
Hyposensitivity To Touch (Under-Responsive): may crave touch, needs to touch everything and everyone is not aware of being touched/bumped unless done with extreme force or intensity is 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 running may be self-abusive; pinching, biting, or banging his own head mouths objects excessively frequently hurts other children or pets while playing repeatedly touches surfaces or objects that are soothing (i.e., blanket) seeks out surfaces and textures that provide strong tactile feedback thoroughly enjoys and seeks out messy play craves vibrating or strong sensory input has a preference and craving for excessively spicy, sweet, sour, or salty foods
Poor Tactile Perception And Discrimination: has difficulty with fine motor tasks such as buttoning, zipping, and fastening clothes may not be able to identify which part of their body was touched if they were not looking may 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 silverware continues to mouth objects to explore them even after age two has 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.
Signs Of Vestibular Dysfunction: Hypersensitivity To Movement (Over-Responsive): avoids/dislikes playground equipment; i.e., swings, ladders, slides, or merry-go-rounds prefers sedentary tasks, moves slowly and cautiously, avoids taking risks avoids/dislikes elevators and escalators; may prefer sitting while they are on them or, actually get motion sickness from them may appear terrified of falling even when there is no real risk of it afraid of heights, even the height of a curb or step fearful of feet leaving the ground fearful of going up or down stairs or walking on uneven surfaces afraid of being tipped upside down, sideways or backwards; will strongly resist getting hair washed over the sink startles if someone else moves them; i.e., pushing his/her chair closer to the table as an infant, may never have liked baby swings or jumpers may 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 infant loses balance easily and may appear clumsy avoids rapid or rotating movements
Hyposensitivity To Movement (Under-Responsive): in constant motion, can't seem to sit still craves fast, spinning, and/or intense movement experiences loves being tossed in the air could spin for hours and never appear to be dizzy loves the fast, intense, and/or ‘scary’ rides at amusement parks always jumping on furniture, trampolines, spinning in a swivel chair, or getting into upside down positions loves to swing as high as possible and for long periods of time is a 'thrill-seeker'; dangerous at times always running, jumping, hopping etc. instead of walking rocks body, shakes leg, or head while sitting
Poor Muscle Tone And/Or Coordination: 'floppy' body' frequently slumps, lies down, and/or leans head on hand or arm while working at his/her desk difficulty simultaneously lifting head, arms, and legs off the floor while lying on stomach ('superman' position) often sits in a 'W sit' position on the floor fatigues easily! compensates for 'looseness' by grasping objects tightly difficulty turning door knobs, handles, opening and closing items difficulty catching him/her self if falling difficulty getting dressed and doing fasteners, zippers, and buttons may have never crawled or limited period of time when did crawl as a baby has poor body awareness; bumps into things, knocks things over, trips, and/or appears clumsy poor 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 old seems 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:
Sensory Seeking Behaviors: seeks out jumping, bumping, and crashing activities stomps feet when walking kicks his/her feet on the floor or chair while sitting at a desk/table loves to be tightly wrapped in many or weighted blankets, especially at bedtime prefers clothes (and belts, hoods, shoelaces) to be as tight as possible loves/seeks out 'squishing' activities, enjoys bear hugs excessive banging on/with toys and objects loves 'rough-housing' and tackling/wrestling games frequently falls on floor intentionally would jump on a trampoline for hours on end grinds his/her teeth throughout the day loves pushing/pulling/dragging objects loves jumping off furniture or from high places frequently hits, bumps or pushes other children chews on pens, straws, shirt sleeves etc.
Difficulty With "Grading Of Movement": difficulty regulating pressure when writing/drawing; may be too light to see or so hard the tip of writing utensil breaks written work is messy and he/she often rips the paper when erasing always seems to be breaking objects and toys misjudges 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 heavy may not understand the idea of 'heavy' or 'light'; would not be able to hold two objects and tell you which weighs more seems to do everything with too much force; i.e., walking, slamming doors, pressing things too hard, slamming objects down plays with animals with too much force, often hurting them
Signs Of Auditory Dysfunction: (no diagnosed hearing problem)
Hypersensitivity To Sounds (Auditory Defensiveness): distracted by sounds not normally noticed by others; i.e., humming of lights or refrigerators, fans, heaters, or clocks ticking fearful of the sound of a flushing toilet (especially in public bathrooms), vacuum, hairdryer, squeaky shoes, or a dog barking started with or distracted by loud or unexpected sounds bothered/distracted by background environmental sounds; i.e., lawn mowing or outside construction frequently asks people to be quiet; i.e., stop making noise, talking, or singing runs away, cries, and/or covers ears with loud or unexpected sounds may refuse to go to movie theaters, parades, skating rinks, musical concerts, firework show etc.
Hyposensitivity To Sounds (Under-Registers): often does not respond to verbal cues or to name being called appears to 'make noise for noise's sake' loves excessively loud music or TV seems to have difficulty understanding or remembering what was said appears oblivious to certain sounds appears confused about where a sound is coming from talks self through a task, often out loud needs directions repeated often, or will say, / What?' frequently'
Signs Of Oral Input
Dysfunction: Hypersensitivity To Oral Input (Oral Defensiveness):
Hyposensitivity To Oral Input (Under-Registers) may lick, taste, or chew on inedible objects prefers foods with intense flavor; i.e., excessively spicy, sweet, sour, or salty excessive drooling past the teething stage frequently chews on hair, shirt, or fingers constantly putting objects in mouth past the toddler years acts as if all foods taste the same can never get enough condiments or seasonings on his/her food loves vibrating toothbrushes and even trips to the dentist
Signs Of Olfactory Dysfunction (Smells):
Hypersensitivity To Smells (Over-Responsive): reacts negatively to, or dislikes smells which do not usually bother, or get noticed by other people tells other people (or talks about) how bad or funny they smell refuses to eat certain foods because of their smell offended and/or nauseated by bathroom odors or personal hygiene smells bothered/irritated by the smell of perfume or cologne bothered by household or cooking smells
Hypersensitivity To Smells (Under-Responsive): has difficulty discriminating unpleasant odors may drink or eat things that are poisonous because they do not notice the noxious smell unable to identify smells from scratch 'n sniff stickers does not notice odors that others usually complain about fails to notice or ignores unpleasant odors makes excessive use of smelling when introduced to objects, people, or places
Signs Of Visual Input Dysfunction (No Diagnosed Visual Deficit):
Hypersensitivity To Visual Input (Over-Responsiveness) sensitive to bright lights; will squint, cover eyes, cry and/or get headaches from the light has difficulty keeping eyes focused on task/activity he/she is working on for an appropriate amount of time easily 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 room rubs his/her eyes, has watery eyes or gets headaches after reading or watching TV avoids eye contact
Hyposensitivity To Visual Input has difficulty telling the difference between similar printed letters or figures; i.e., p & q, b & d, + and x, or square and rectangle has a hard time seeing the 'big picture'; i.e., focuses on the details or patterns within the picture has 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 box often loses place when copying from a book or the chalkboard difficulty controlling eye movement to track and follow moving objects has difficulty telling the difference between different colors, shapes, and sizes often loses his/her place while reading or doing math problems makes reversals in words or letters when copying, or reads words backwards; i.e., 'was' for 'saw and 'no' for 'on' after first grade complains about 'seeing double' difficulties finding differences in pictures, words, symbols, or objects difficulty with consistent spacing and size of letters during writing and/or lining up numbers in math problems difficulty with jigsaw puzzles, copying shapes, and/or cutting/tracing along a line tends to write at a slant (up or down hill) on a page confuses left and right fatigues easily with schoolwork difficulty judging spatial relationships in the environment; i.e., bumps into objects/people or missteps on curbs and stairs
Auditory-Language Processing Dysfunction: unable to locate the source of a sound difficulty identifying people's voices difficulty discriminating between sounds/words; i.e., 'dare' and 'dear' difficulty filtering out other sounds while trying to pay attention to one person talking bothered by loud, sudden, metallic, or high-pitched sounds difficulty 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 time looks at others to/for reassurance before answering difficulty 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 up difficulty reading, especially out loud (may also be dyslexic) difficulty articulating and speaking clearly ability to speak often improves after intense movement
Emotional Response, Play, And Self-Regulation Dysfunction:
Emotional: difficulty accepting changes in routine (to the point of tantrums) gets easily frustrated often impulsive functions best in small group or individually variable and quickly changing moods; prone to outbursts and tantrums prefers to play on the outside, away from groups, or just be an observer avoids eye contact difficulty appropriately making needs known
Play: 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.
Self-Regulation: excessive irritability, fussiness or colic as an infant can't calm or soothe self through pacifier, comfort object, or caregiver can't go from sleeping to awake without distress requires excessive help from caregiver to fall asleep; i.e., rubbing back or head, rocking, long walks, or car rides
Internal Regulation (The Interoceptive Sense): 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 days difficulty 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 full unable to regulate hunger; eats all the time, won't eat at all, unable to feel full/hungry
Please provide any additional information that will help to better understand your child:
Back Next
I love bringing my little one here. I've notice such a big difference in her speech. And Ms.Rachel is amazing just amazing. My little one is always excited to come and see her since day 1. Everyone here is amazing such great energy. I always see little ones come excited and leave excited!
