Multisensory Inventory Assessment Checklist
Designed by Celia Hinrichs, OD, FCOVD & Randy Schulman MS, OD, FCOVD
Name
First Name
Last Name
Phone Number
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Date of Birth
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Month
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Day
Year
Date
Today's Date
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Month
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Day
Year
Date
Please use the following to rate the statements below:
0 = Never 1 = Rarely 2 = Sometimes 3 = Frequently 4 = Always
Proprioceptive/Kinesthetic
Responds differently to touch either very sensitive or needs deep pressure or touches everything
Never
1
2
3
Always
4
1 is Never, 4 is Always
Has difficulty maintaining posture, spreads legs/uses arms to support core or unusually still
Never
1
2
3
Always
4
1 is Never, 4 is Always
Has difficultyperforming gross and fine motor tasks such as writing, ball catching, skipping
Never
1
2
3
Always
4
1 is Never, 4 is Always
Clumsy or awkward, falls over and loses balance easily or uses momentum to maintain balance
Never
1
2
3
Always
4
1 is Never, 4 is Always
VESTIBULAR
Dizziness
Never
1
2
3
Always
4
1 is Never, 4 is Always
Disorientation, feelingoff-balance, as if floating or the world is spinning
Never
1
2
3
Always
4
1 is Never, 4 is Always
Nausea/Lightheadedness or feeling faint
Never
1
2
3
Always
4
1 is Never, 4 is Always
Resists moving
Never
1
2
3
Always
4
1 is Never, 4 is Always
BALANCE
Falling or stumbling
Never
1
2
3
Always
4
1 is Never, 4 is Always
Unstable gait, unsteadiness,or inconsistencies in balance
Never
1
2
3
Always
4
1 is Never, 4 is Always
AUDITORY
Seemsdistracted/unable to sustain attention when receiving verbal messages, needs tohear instructions/directions more than once
Never
1
2
3
Always
4
1 is Never, 4 is Always
Differently sensitive to sound, appears overwhelmed with excess auditory activity or background sounds
Never
1
2
3
Always
4
1 is Never, 4 is Always
Has problems withreceptive and expressive language
Never
1
2
3
Always
4
1 is Never, 4 is Always
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