SENSORY QUIZ
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please use the following to rate the statements below:
0 = Never 1 = Rarely 2 = Sometimes 3 = Frequently 4 = Always
PROPRIOCEPTIVE/KINESTHETIC
Rows
0
1
2
3
4
Responds differently to touch either very sensitive, needs deep pressure, or touches everything
Has difficulty maintaining posture, spreads legs/uses arms to support core or unusually still
Has difficulty performing gross and fine motor tasks such as writing, ball catching, skipping
Clumsy or awkward, falls over and loses balance easily or uses momentum to maintain balance
Total Proprioceptive/Kinesthetic
VESTIBULAR
Rows
0
1
2
3
4
Dizziness
Disorientation, feeling off-balance, as if floating or the world is spinning
Nausea/Lightheadedness or feeling faint
Resists moving
Total Vestibular
BALANCE
Rows
0
1
2
3
4
Falling or stumbling
Unstable gait, unsteadiness, or inconsistencies in balance
Total Balance
AUDITORY
Rows
0
1
2
3
4
Seems distracted/unable to sustain attention when receiving verbal messages, needs to hear instructions/directions more than once
Differently sensitive to sound, appears overwhelmed with excess auditory activity or background sounds
Has problems with receptive and expressive language
Total Auditory
INTEROCEPTION
Rows
0
1
2
3
4
Has palpable fears and anxiety, easily startled, particularly sensitive to or unaware of environment
Has trouble falling or staying asleep or staying awake
Has eating or bowel difficulties
Total Interoception
VISION
Rows
0
1
2
3
4
Blurred vision, double vision, eye turn, squinting, or closing an eye
Light sensitivity, burning, tearing, or watering eyes
Headaches
Moves head or uses a finger while reading, loses place, misreads, reverses words or numbers or has poor reading comprehension
Gets frustrated by or avoids near tasks
Total Vision
ATTENTION
Rows
0
1
2
3
4
Loses train of thought, extensive off task time, distracted easily
Difficulty following directions
Difficulty organizing tasks, forgets to complete tasks
Difficulty remembering steps in a multi-step process
Total Attention
AUTOMATICITY/COGNITIVE LOADING
Rows
0
1
2
3
4
Does the task, but requires full attention
Cannot repeat the task, fatigues quickly
Requires motor overflow, subvocalization to complete the task
Reduced efficiency
Total AUTOMATICITY/COGNITIVE LOADING
TOTAL ANSWER
Would you like our office to contact you to schedule an appointment?
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