Sensory History

Sensory History

Child's Name

Today's Date

For each question, please choose what best describes your child. (Please compare with other children you know of the same age.)

Tactile Sensation:

Does your child:

1. Object to being touched?

2. Seem irritable when held?

3. Isolate self from other children?

4. Avoid/dislike getting hands messy?

5. Become upset when face is being washed?

6. Become upset when having hair combed, fingernails clipped or teeth brushed?

7. Prefer long sleeve clothing, sweaters, or jackets even when it's warm?

8. Seem sensitive to certain fabrics and avoid wearing clothes made of them?

9. Have trouble changing to new types of clothing when seasons change? (i.e. From long pants to shorts)

10. Avoid going barefoot? (i.e. In sand or grass)

11. Become irritated by tags on clothing?

12. Seem to crave being held or cuddled?

13. Express discomfort when touched by other people, even as in a friendly hug or pat?

14. Tend to bump or push others?

15. Seem overly sensitive to pain? (i.e. Especially bothered by small cuts)

16. Seem less sensitive to pain than others? (i.e. To falls and bruises)

17. Mouth objects or clothing often?

18. Have difficulty judging how much strength to use? (i.e. When petting animals may use too much force)

Auditory Sensation

Does your child:

19. Seem overly sensitive to sound?

20. Seem confused about the direction of sounds?

21. Like to make loud noises?

22. Become distracted or have trouble if there is a lot of noises around?

23. Respond negatively to unexpected or loud noises?

Gustatory Sensation

Does your child:

24. Act as though all food tastes the same?

25. Explore by tasting?

26. Dislike food of a certain texture?

27. Chew or lick non-food items?

Olfactory Sensation

Does your child:

28. Explore objects by smelling them?

29. Discriminate odors?

30. React defensively to smell?

31. Seem bothered by smells that most other people don't notice?

Visual Sensation

Does your child:

32. Become easily distracted by visual stimulation?

33. Express discomfort at bright lights?

34. Avoid or have difficulty with eye contact?

35. Have a hard time picking out a single object from many? (i.e. Finding a specific toy in the toy box)

36. Have difficulty with a camera flash, seems irritated by it?

Vestibular Sensation

Does your child:

37. Chew or lick non-food items?

38. Seem fearful in space (i.e. Going up & down stairs, riding a tricycle?)

39. Appear clumsy, often bumping into things &/or falling down?

40. Prefer fast-moving, spinning carnival rides?

41. Have poor balance?

42. Become anxious or distressed when his/her feet leave the ground?

43. Avoid climbing or jumping?

44. Dislike elevators or escalators?

45. Dislike riding in a car?

46. Disklike activities where head is upside down or when lifted overhead? (such as with hair washing or somersaults)

47. Love to be tipped upside down or lifted overhead?

48. Seek out all kinds of movement activities?

49. Jump a lot on beds or other surfaces?

50. Like to spin him/herself?

51. Bang his/her head on purpose?

52. Throw him/herself against the floor, wall or other people for enjoyment? (likes to "crash")

53. Take unusual risks during play?

Coordination Sensation

Does your child:

54. Manipulate small objects easily?

55. Seem accident prone? (i.e. Have frequent scrapes and bruises)

56. Neglect one side of the body or seem unaware of it?

57. Use one hand more than the other?


Does your child:

58. Need assistance to feed him/herself?

59. Tend to eat in a sloppy manner?

60. Frequently spill liquids?

61. Drool?

62. Have trouble chewing?

63. Have trouble swallowing?

64. Have difficulty eating foods with lumps?

65. Stuff or put too much food in his/her mouth?