OT survey

JenLo Therapy Farm

Julie Abrams MS,OTR/L

Amanda Betzen, MS, OTR/L

Name of Child

Diagnosis

Medications and reason for prescribing and any allergies

Any Developmental Delays in Motor?

Any Developmental Delays in Language?

Any Developmental Delays in Social?

Did your child crawl? For how long? When did s/he walk?

Does your child have an IEP or 504?

Any early milestones or gifts

Please describe your goals for therapy

Please describe previous evaluations or therapies your child has received, including date, duration, and effectiveness.

Describe extracurricular activities your child has been/is involved in (include successes and difficulties

What kind of play does your child prefer

What best motivates/reinforces your child

How much screen time does your child get per day

Per week

What kind of screen

How does your child respond when the screen is taken away

Any other information you would like to share that would be helpful?

Activities of Daily Living

Can your child do these activities independently and/or do they have difficulty with the following...

Does your child dress themselves

Brush Teeth

Able to take a bath or a shower regularly

Eat a wide variety of foods

Fall asleep on their own andor sleep through the night

All children respond to the world in their own way. Looking at how they respond through their senses can help us understand them and give a clearer idea of how to help them.

Please mark the number that best describes the frequency or intensity of the responses. Add comments when additional information is necessary.

Tactile

Bothered by textures of clothing (tags, turtlenecks, socks, etc)

Upset with grooming (hair, face washed, nails cut, tooth brushing)

Dislikes going barefoot (in grass or sand, etc)

Dislikes finger painting, sand play, paste, mud, etc

Dislikes being dirty

Unaware when hurt

Hurt Easily

Bothered When Standing in Line

Craves Certain Types of Touch

Comments on Tactile Section

Sensitive to Sounds

Needs Directions Repeated

Likes to make loud sounds

Has had many ear infections

Comments on Sounds

Sensitive to certain smells

Ignores noxious or strong odors

Smells food or objects for exploration

Comments on Smell Section

Sensitive to certain textures of food

Sensitive to temperature of food

Craves certain foods

Mouths Objects

Comments on Taste/Texture

Difficulty keeping eyes on objects

Uses head movements when visually tracking

Sensitive to light

Rubs eyes or complains of headaches

Distracted by visual input

Reverses letter or words

Comments on Vision Section

Fearful of ladders, stairs, teeter-totters, swings

Gets motion sickness

Dislikes/fearful of trying new movement activities

Likes spinning or fast moving activities

Does not catch self easily when falls

Moves faster or slower than other children (please indicate in comments)

Comments on Movement

Slouches when sitting or standing

Tires Easily

Seems stronger or weaker than average

Has tight or weak grasp

Seems accident prone or clumsy

Difficulty hopping, skipping, running, jumping

Hard time using both hands together

Comments on Muscle Strength and Coordination

Very Active

Needs movement to stay focused

Difficulty waiting for things

Difficulty sitting still

Short attention span

Sometimes aggressive

Poor impulse control

Easily frustrated

Self-stimulating behavior

Poor concept of time

Easily lost

Generally Disorganized

Cries Easily

Underactive

Poor Self Confidence

Sensitive to criticism

Avoided by other children

Difficulty playing with peers

Sensory Motor Survey

Sounds

Smells

Taste/Texture

Vision

Movement

Muscle Strength and Coordination

Please comment on applicable descriptors below