Sensorimotor History

Sensorimotor History
Please complete the following form to help us gain more information to determine the needs of your child:
Child's Name:*

First NameLast Name
Date:

MonthDayYear
Person completing form:*
Relationship to child:*
Significant medical history including major illness, accidents or incidents, and date of occurence:
Developmental History
Birth History
Check All Applicable:*

Full TermPrematureBreechCaesarianDifficult LaborForcepsSuction
Birth weight:*
List any complications or other significant information regarding prenatal period/birth. This information is important in our understanding of how to best approach intervention for your child, as it can impact sensory and motor development:
Developmental Milestones
Check All Applicable:

Reflux/GI IssuesColicDifficulty SleepingLimited Self-SoothingTorticollis
Give approximate age of mastery, if known:
Rolling over: Age 1-2 words: Age
Using sentences:    Age
Potty Training (Day):       Age   Potty Training (Night):    Age
Establishment of Regular Sleep/Wake Cycles:    Age
Falling Asleep Independently:    Age
Did your child master a smooth and symmetrical crawl for a minimum of 1-2 months?*

YesNo
If no, please describe:
Do you notice any asymmetry in your child?*

YesNo
Describe:
Does your child sleep well?

YesNo
Describe:
About Your Child:
Please describe your child's morning and evening routines (including level of assistance required):
How is sleep and bedtime/wake up routine? Any challenges with falling asleep or staying asleep?
What is your child's level of independence and/or ability to tolerate participation in dressing/undressing and completing self-care and grooming tasks (brushing teeth, bathing, washing/brushing hair):
Can you describe what your typical mealtime environment looks like at home? Does your child sit at a separate table to eat or with others? What is their seating like? Position or location of feeding? Do you use distraction as a tool to help with feeding?
Please describe mealtimes with your child. Include all relevant information, including where your child eats, whether he/she eat meals with the rest of the family, and level of assistance required for self-feeding:
Please describe the level of safety awareness your child exhibits at home and within the community:
Please list any concerns you have (if any) related to your child's social skills and interactions:
Is your child able to play independently? What are your child's favorite activities?
What things does your child seem to fear or avoid, if any?
Please list any questions or concerns that you would hope this screening/evaluation would answer:
Do you have any tips or strategies to suggest when working with your child?
What are your child's greatest strengths?
Is there anything else that you would like for us to know about your child?
Please upload any files/records you would like to share with us:

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Sensorimotor History

Developmental History

Birth History

Developmental Milestones

About Your Child: