Sensory Quiz

Name*

First NameLast Name

Date of Birth*

Date

Please use the following to rate the statements below:

0 = Never 1 = Rarely 2 = Sometimes 3 = Frequently 4 = Always

PROPRIOCEPTIVE/KINESTHETIC

	0	1	2	3	4
Responds differently to touch either very sensitive or 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

	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

	0	1	2	3	4
Falling or stumbling
Unstable gait, unsteadiness, or inconsistencies in balance

Total Balance

AUDITORY

	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

	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

	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

	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

	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 efficienc

Total AUTOMATICITY/COGNITIVE LOADING

Phone Number*

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TOTAL ANSWER