Sensory History Form
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  • SENSORY HISTORY FORM

  • Today's Date
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  • FOR EACH QUESTION, CHOOSE THE OPTION THAT BEST DESCRIBES YOUR CHILD. (PLEASE COMPARE WITH OTHER CHILDREN YOU KNOW OF THE SAME AGE.)

  • QUESTIONS - TACTILE SENSATIONS

     

     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/Chew objects or clothing often?
  • 18. Have difficulty judging how much strength to use? (i.e. when petting animals may use too much force)

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  • SENSORY HISTORY FORM - PAGE 2

  • QUESTIONS - AUDITORY SENSATIONS

     

     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?

  • QUESTIONS - GUSTATORY SENSATIONS

     

     Does your child:

  • 24. Act as though all foods taste the same?
  • 25. Explore by tasting?
  • 26. Dislike foods of a certain texture?
  • 27. Chew or lick non-food items?

  • QUESTIONS - OLFACTORY SENSATIONS

     

     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?

  • QUESTIONS - VISUAL SENSATIONS

     

     Does your child:

  • 32. Become easliy 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?

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  • SENSORY HISTORY FORM - Page 3

  • QUESTIONS - VESTIBULER SENSATIONS

     

     Does your child:

  • 37. Seem fearful in space? (i.e. going up & down stairs, riding a tricycle)
  • 38. Appear clumsy, often bumping into things &/or falling down?
  • 39. Prefer fast-moving, spinning carnival rides?
  • 40. Have poor balance?
  • 41. Become anxious or distressed when his/her feet leave the ground?
  • 42. Avoid climbing or jumping?
  • 43. Dislike elevators or escalators?
  • 44. Dislike riding in a car?
  • 45. Dislike activities where head is upside down, or when lifted overhead? (i.e. such as with hairwashing or summersaults)
  • 46. Love to be tipped upside down, or lifted overhead?
  • 47. Seek out all kinds of movement activities?
  • 48. Jump a lot on beds or other surfaces?
  • 49. Like to spin him/herself?
  • 50. Bang his/her head on purpose?
  • 51. Throw him/herself against the floor, wall, or other people for enjoyment? (like to "crash")
  • 52. Take unusual risks during play?

  • QUESTIONS - COORDINATION

     

     Does your child:

  • 53. Have difficulty manipulating small objects easily or troubling staying in lines to color?
  • 54. Seem accident prone? (i.e. frequent tripping or walking into objects)
  • 55. Neglect one side of the body or seem unaware of it?
  • 56. Have difficulty deciding what hand to use, left or right?

  • QUESTIONS - FEEDING

     

     Does your child:

  • 57. Need assistance to feed him/herself?
  • 58. Tend to eat in a sloppy manner?
  • 59. Frequently spill liquids?
  • 60. Drool?
  • 61. Have trouble chewing?
  • 62. Have troubling swallowing?
  • 63. Have difficulty eating foods with lumps?
  • 64. Stuff, or put too much food in his/her mouth?
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  • SENSORY HISTORY FORM

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