Child’s name_________________________ Birth Date________________

Age _____

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

Independent (completes without help)

Dependent (total assistance needed)

Describe your child at present:

Socialize with family and close friends?

Communicate needs and wants effectively?

Tend to interact/play with younger children?

In the community, does your child:

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 sensory behaviors.

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

a raindrop, water from the shower, or wind blowing on the skin may feel like torture and produce

adverse and avoidance reactions

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

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.

an established hand preference/dominance by 4 or 5 years old

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

stomps feet when walking kicks his/her feet on floor or chair while sitting at 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 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)

distracted by sounds not normally noticed by others; i.e., humming of lights or refrigerators, fans, heaters, or clocks ticking

resistive to trying new foods or restaurants, and may not eat at other people's houses)

no" for "on" after first grade

vacillating between the two; over stimulated to under stimulated, within hours or days, depending on activity and setting, etc.)

necessary sensation that bowel or bladder are full

Thank you! Kristen DeMont, OTR/L Licensed Occupational Therapist Family Guidance and Therapy Center

Family Guidance and Therapy Center, Petaluma

Address: 135 Keller St Suite C, Petaluma, CA 94952 (707) 533-1230