Short Sensory Profile

Child's Name:

First NameLast Name

Child's DOB:

Date

Gender:

MaleFemale

Completed by/Caregiver's Name:

First NameLast Name

Relationship to child:

Name of School/Daycare:

School Grade Level:

In what order was your child born in relation to siblings (for example, 1st child, 3rd child, etc.)?

Have there been more than three children between the ages of birth through 18 years living in your household during the past 12 months?

YesNo

INSTRUCTIONS

The pages that follow contain statements that describe how children may act. Please read each phrase and select the option that best describes how often your child shows these behaviors. Please mark one option for every statement.

Use these guidelines to mark your response:

When presented with the opportunity, my child...

Almost Always: responds in this manner Almost Always (90% or more of the time).

Frequently: responds in this manner Frequently (75% of the time).

Half the Time: responds in this manner Half of the Time (50% of the time).

Occasionally: responds in this manner Occasionally (25% of the time).

Almost Never: responds in this manner Almost Never (10% or less of the time).

Does Not Apply: If you are unable to answer because you have not observed the behavior or believe that it does not apply to your child, please check DOES NOT APPLY.

Sensory Processing: My Child...

Rows	Almost Always 5	Frequently 4	Half the Time 3	Occasionally 2	Almost Never 1	Does Not Apply 0
1. Struggles to complete tasks when music or TV is on.
2. is distracted when there is a lot of noise around.
3. tunes me out or seems to ignore me.
4. shows distress during grooming (for example, fights or cries during haircutting, face washing, fingernail cutting).
5. becomes anxious when standing close to others (for example, in a line).
6. touches people and objects more than same aged-children.
7. pursues movement to the point it interferes with daily routines (for example, can't sit still, fidgets.)
8. rocks in chair, on floor, or while standing.
9. loses balance unexpectedly when walking on an uneven surface.
10. bumps into things, failing to notice objects or people in the way.
11. shows a strong preference for certain tastes.
12. moves stiffly.
13. becomes tired easily, especially when standing or holding the body in one position.
14. drapes self over furniture or on other people.

Sensory Processing Comments:

Behavioral Reponses Associated with Sensory Processing: My Child...

Rows	Almost Always 5	Frequently 4	Half the Time 3	Occasionally 2	Almost Never 1	Does Not Apply 0
15. seems accident prone
16. can be stubborn and uncooperative.
17. has temper tantrums.
18. resists eye contact from me or others.
19. needs positive support to return to challenging situations.
20. has strong emotional outbursts when unable to complete a task.
21. struggles to interpret body language or facial expressions.
22. gets frustrated easily.
23. has fears that interfere with daily routines.
24. is distressed by changes in plans, routines, expectations.
25. needs more protection from life than same-aged children (for example, defenseless physically or emotionally).
26. interacts or participates in groups less than same aged children.
27. misses eye contact with me during everyday interactions.
28. struggles to pay attentions.
29. looks away from tasks to notice all actions in the room.
30. seems oblivious within an active environment (for example, unaware of activity.
31. watches everyone when they move around the room.
32. Jumps from one thing to another that it interferes activities.
33. gets lost easily.
34. has a hard time finding objects in competing backgrounds (for example, shoes in a messy room, pencil in "junk drawer")

Behavioral Responses Comments: