SENSORY PROFILE Winnie Dunn, Ph.D, OTR, FAOTA Caregiver Questionnaire Childs Name: a Birth Date: _ Date: Completed by: Relationship to Chil Service Providers Name: __ Discipine einen) eter OCCASIONALLY Eat fora) Copyright © 1999 by The Paychologeal Corporation. Al ight reserved No part of hs publication may be reproduced or wanamitd in ay form or by any means electronic or ‘mechanical, including photocopy, recording, or any information storage and retrieval system, without permis Os FEF OLOGICAL ‘Son m wring forthe publisher pyc ror oGce The Psychological Corpration and th Plog ar registred tademarks of The Psychologica Corporation ‘Avorcour Assessment Company Pint i the United States of America 91011 12ABCDE ‘0761630059Salers) Ce oo ace) Responds negatively to unexpected or loud noises (lor example, cries or hides at noise rom vacuum clezner, dog batkng, hairdryer) Holds hands over ear to prteot ears from sound Has trouble completing tasks when the rao ison ls distracted or has trouble functioning if there salt of noise around Can't work wth background nese (lor example, fan, refigerato) [ “Appears to not hear what you say (for example, does nat Tunesn to what you £8, appears to ignore you) Doesn't respond when name i called but you know the childs hearing is OK Enjoys stange noises/eeeks to make noise for nloe’s sake ‘Section Raw Score Total mee ® refers tobe in the dark presses discomfort wih or avoids bight ights (or example, Rides Wom aunight ® through window in ae) © Happy tobe in the dark ‘Becomes rusated when ining fo fnd objets in comping backgrounds oe (for example, a clatored drawer) © Has diftcul puting puzzes together (as compared to same age cidren) © Ts bothored by bright lighs afer others have adapted othe Fight © Covers eyes or squints to protect eyes rom ight oy Looks careluly or intensely at objcte/people (or example, saree) Has a hard ime finding objec n Competing backgrounds for erample, shoes ina 2 messy room, favorite toy inthe “unk drawer) | ‘Section Raw Score TotalCe daeeen) ‘Becomes arvious or distressed when feet leave the ground Dias actives where head is upside down (for exemple, somersaults, roughhousng) "hide playground equipment or moving toys (lor example, sing set, memy-goround) Dislikes riding in a car Ties head upright, even when banding over or ering (lor example, maintains ‘iid poston/postue during actity) ‘Becomes disoriented after bending over sink o abe fr example fle or gets izzy) Socks al Keds of movement and this interferes wih daly routines (for example, can't it til idget) Socks out al nds of movement ates (or example, being whired by adult, rmery-go-tounds, playground equipment, moving toys) Twis/epne self equetly throughout the day (or example, kes czy feeling) Rocks unconsciously (for example, while watching TV) Rocks in deskchaitfon floor ‘Section Raw Score Total| ‘Avoids gating "messy" (or example, in paste, sand, finger pant, glue, tape) Expresses distress during grooming (ar example, fights or eres dung haircuting, face washing, ingema cutting) Prefers long-sleeved clothing when itis warm or short loaves when itis cold Expresses discomfort at dental work or toothbrushing (fr example, ces or fights) 's sensitive to certain fabrics fe example is particular about certain clothes or bedsheets) ‘Beecomes irate by shoes or socks ‘Avoids going barefoot, especially in sand or grass Reacts emotionally or aggressively to touch ‘Withdraws from splashing water Has dificuty standing in Ine or close to other people Rubs or soratches outa spot that has been touched “Touches people and abjects tothe point of tating others Displays unusual need for touching certain toys, surfaces or textures (for example, constant touching objects) Decreased awareness of pain and temperature Doesn't seem to natice when someone touches arm or back fr example, unaware) ‘Avoids wearing shoes; loves to be barefoot RYOBI ERY IER] Ce [ERIC] CR CR | CORI ER CR. Comments Touches people and objects Doesn't seem to notice when face oc hands are messy Section Raw Scare Total Gets lst easiy (oven in familiar places) Has ditfcuty paying attention [Looks away rom tasks to natce all actions inthe room ‘Seoms oblivious within an active environment (or example, unaware of atv) Hangs on poop, furiture, or objects oven in fail situations ER )>+>+/9] @ 154) @ Comments Walks on toes Leaves clothing twisted on body ‘Section Raw Score TotalGage easly wit fod textures oF food ten in mouth ‘Avoids certain tastes or fod smalls that are typicaly part of children's dts Wil only eat certain tastes (st Limits set particular food testureitemperatures (is: Picky eater, especialy regarding feod textures Routinely amelie nanfoad abjects ‘Shows song preference fr certain aml ie. Shows song preference fr an tastes (it: Caves certain foods (it: Seeks out certain tastes or mel ist:_ 10 10 |G 1G 1G |G |r| 0 |G |e ‘Chews or ike on nonfood objects Mouths objects fr example, pencl, hands) Comments Section Raw Score Total Moves sti Ml “Tires easy, eepecially when standing or holding particular body postion Locks joints (or example, elbows, knees) for stably Soome to have weak muscles Has a weak grasp Ca heavy objects (lor example, weak in comparison to same age cider) | Props to support self (even during activity) Poor endurancelires easily LL fet lot] >t tl >t lott ‘Appears lethargic (for example, has no energy is sluggish) Section Raw Score Total CommentsH. Modulation Related to Body Position and Movement Seems accident prone estates going up or down curbs or steps (fr example is cautious, stops before moving) Fears fling or heights ‘Avoids cimbinglumping or avoids bumpy/uneven ground: Holds onto walls or banister (or example, cings) Takes excessive sks during play fr example, climbs high into a tree, jumps of tal frit) Takes movernent or cimbing risks during play that compromise personal safety Turns wihele body to look at you ‘Seeks opportunites to fal without regard to personal safety p4}>+| | L/L] L |b] L)o}o ‘Appears to enioy fling ‘Section Raw Score Total Comments tern Louie ‘Spends most ofthe day in sedentary play (for example, does quiet things) Prefers quiet, sedentary play (lor example, waiching TV, books, computers) ‘Seeks sedentary play options Prefers sedentary activites ‘Becomes overly excitable during movement activity “On the go" salon] Uv] yal ‘Avoids quiet pay activites ‘Section Raw Score Total Comments Wen em ‘Needs more protection from ie than athe olden (for example, defenseless physically or emotional) Rigi ritual in personal hygiene Ts overyafectionate with others ‘Doesrit perceive body language o facial expressions (for example, unable to interpret) ‘Section Raw Score Totaler eee Lo Avoids eye contact Ma ‘Stare intensively at objects or people Watches everyone when they move around the room 0|0/6)0 Comments Bi cl EOI haan ea Doesnt ntice when people come ito the room Section Raw Score Total eens ‘Seems to have dificult Bking sl (or example, low seltesteem) Mh Has trouble “growing up* (lor example, reacts immaturly to situations) Is sensitive to crits Has dete fears (ior example, fers are predictable) ‘Seems ansious Displays excessive emotional outbursts when unsuccessful ata task Expresses feeling tho a fluro Is stubborn or unccoperatve Has temper tantrums Poor frustration tolerance Cries easily Overy serious Has dificuly making frends fo example, does not interact or participate in group play) Has nightmares | Hae fear that intrtre with daly routine Doesn't have a sense of humor alalalala|alala|a]ala|alalalala}a Comments Doesn't express emotions Section Raw Score Totaleee kaeeesa) Talks so though tasks Wing is egile Has rouble staying between the ines when coloring or when wating ‘Uses ficient ways of doing things (fr example, wastes time, moves slow, does things a harder way than is needed) Comments Has dificult tolerating changes in plans and expectations Has sificuly tolerating changes in routines ‘Section Raw Score Total IN. tems Indicating Thresholds for Response Jumps fom one activity to another so that it interfres with play Deiiberately smels objects ‘Does not seem to smell strong odors ‘Section Raw Score Total 1S8N_076-1638-05-9 I 78076 186.