Adolescent/ Adult Sensory Profile

Child's Name:*

First NameLast Name

Birth Date*

MonthDayYear

Age:*

Gender:

MaleFemale

Date:

Date

Are there aspects of daily life that are not satisfying to you? If yes, please explain.

Instructions

Please check the box that Best describes the frequency with which you perform the following behaviors. If you are unable to comment because you have not experienced a particular situation, please draw an X through that item's number. Write any comments at the end of each section.

Please answer all of the statements. Use the following key to mark your responses:

Almost Never: When presented with the opportunity, you must almost never respond in this manner (about 5% or less of the time).

Seldom: When presented with the opportunity, you seldom respond in this manner (about 25% of the time).

Occasionally: When presented with the opportunity, you occasionally respond in this manner (about 50% of the time).

Frequently: When presented with the opportunity, you frequently respond in this manner (about 75% of the time).

Almost Always: When presented with the opportunity, you almost always respond in this manner (about 95% of the time).

A. Taste/Smell Processing

	Almost Never	Seldom	Occasionally	Frequently	Almost Always
1.) I leave or moved to another section when I smell a strong odor in a store (for example, bath products, candles, perfumes).
2.) I add spice to my food.
3.) I don't smell things that other people say they smell.
4.) I enjoy being close to people who wear perfume or cologne.
5.) I only eat familiar foods.
6.) Many foods taste bland to me (in other words, food taste plain or does not have a lot of flavor.
7.) I don't like strong tasting mints or candies ( for example, hot/cinnamon or sour candy).
8.) I go over to smell fresh flowers when I see them.

B. Movement Processing

	Almost Never	Seldom	Occasionally	Frequently	Almost Always
9.) I'm afraid heights
10.) I enjoy how it feels to move about (for example, dancing, running).
11.) I avoid elevators and/or escalators because I dislike the movement.
12.) I trip or bump into things
13.) I dislike the movement of riding in a car.
14.) I choose to engage in physical activities.
15.) I am unsure of footing when walking on stairs (for example, I trip, lose balance, and/or need to hold the rail).
16.) I become dizzy easily (for example, after bending over, getting up too fast.

C.Visual Processing

	Almost Never	Seldom	Occasionally	Frequently	Almost Always
17.) I like to go places that have bright lights and that are colorful.
18.) I keep the shades down during the day when I am at home.
19.) I like to wear colorful clothing.
20.) I become frustrated when trying to find something in a crowded drawer or messy room.
21.) I miss the street, building, or room signs when trying to go somewhere new.
22.) I am bothered by unsteady or fast moving visual images in movies or TV.
23.) I don't notice when people come into the room.
24.) I choose to shop in smaller stores because I am overwhelmed in large stores.
25.) I become bothered when I see lots of movement around me (for example, at a busy mall, parade, carnival).
26.) I limit distractions when I am working (for example, I close the door, or turn off the TV).

D. Touch Processing

	Almost Never	Seldom	Occasionally	Frequently	Almost Always
27.) I dislike having my back rubbed.
28.) I like how it feels to get my hair cut.
29.) I avoid or wear gloves during activities that will make my hands messy.
30.) I touch others when I'm talking (for example, I put my hand on their shoulder or shake their hands).
31.) I am bothered by the feeling in my mouth when I wake up in the morning.
32.) I like to go barefoot.
33.) I'm uncomfortable wearing certain fabrics (for example, wool, silk, corduroy, tags in clothing).
34.) I don't like particular food textures (for example, peaches with skin, applesauce, cottage cheese, chunky peanut butter).
35.) I move away when others get too close me.
36.) I don't seem to notice when my face or hands are dirty.
37.) I get scrapes or bruises but don't remember how I got them.
38.) I avoid standing in lines or standing close to other people because I don't like to get too close to others.
39.) I don't seem to notice when someone touches my arm or back.

E. Activity Level

	Almost Never	Seldom	Occasionally	Frequently	Almost Always
40.) I work on two or more tasks at the same time.
41.) It takes me more time than other people to wake up in the morning.
42.) I do things on the spur of the moment ( in other words, I do things without making a plan ahead of time).
43.) I find time to get away from my busy life and spend time by myself.
44.) I seem slower than others when trying to follow an activity or task.
45.) I don't get jokes as quickly as others.
46.) I stay away from crowds.
47.) I find activities to perform in front of others (for example, music, sports, acting, public speaking, and answering questions in class).
48.) I find it hard to concentrate for the whole time when sitting in a long class or a meeting.
49.) I avoid situations where unexpected things might happen (for example, going to unfamiliar places or being around people I don't know).

F. Auditory Processing

	Almost Never	Seldom	Occasionally	Frequently	Almost Always
50.) I hum, whistle, sing, or make other noises.
51.) I startle easily at unexpected or loud noises (for example, vacuum cleaner, dog barking, telephone ringing).
52.) I have trouble following what people are saying when they talk fast or about unfamiliar topics.
53.) I leave the room when others are watching TV, or I ask them to turn it down.
54.) I am distracted if there is a lot of noise around.
55.) I don't notice when my name is called.
56.) I use strategies to drown out sound (for example, close the door, cover my ears, wear ear plugs).
57.) I stay away from noisy settings.
58.) I like to attend events with a lot of music.
59.) I have to ask people to repeat things.
60.) I find it difficult to work with background noise (for example, fan, radio).

Adolescent/Adult Sensory Profile