OT survey

JenLo Therapy Farm

Julie Abrams MS,OTR/L

Amanda Betzen, MS, OTR/L
Name of Child
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
Sensory Motor Survey
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)

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

NeverSeldomOccasionallyFrequentlyAlways
Dislikes going barefoot (in grass or sand, etc)

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

NeverSeldomOccasionallyFrequentlyAlways
Dislikes being dirty

NeverSeldomOccasionallyFrequentlyAlways
Unaware when hurt

NeverSeldomOccasionallyFrequentlyAlways
Hurt Easily

NeverSeldomOccasionallyFrequentlyAlways
Bothered When Standing in Line

NeverSeldomOccasionallyFrequentlyAlways
Craves Certain Types of Touch

NeverSeldomOccasionallyFrequentlyAlways
Comments on Tactile Section
Sounds
Sensitive to Sounds

NeverSeldomOccasionallyFrequentlyAlways
Needs Directions Repeated

NeverSeldomOccasionallyFrequentlyAlways
Likes to make loud sounds

NeverSeldomOccasionallyFrequentlyAlways
Has had many ear infections

NeverSeldomOccasionallyFrequentlyAlways
Comments on Sounds
Smells
Sensitive to certain smells

NeverSeldomOccasionallyFrequentlyAlways
Ignores noxious or strong odors

NeverSeldomOccasionallyFrequentlyAlways
Smells food or objects for exploration

NeverSeldomOccasionallyFrequentlyAlways
Comments on Smell Section
Taste/Texture
Sensitive to certain textures of food

NeverSeldomOccasionallyFrequentlyAlways
Sensitive to temperature of food

NeverSeldomOccasionallyFrequentlyAlways
Craves certain foods

NeverSeldomOccasionallyFrequentlyAlways
Mouths Objects

NeverSeldomOccasionallyFrequentlyAlways
Comments on Taste/Texture
Vision
Difficulty keeping eyes on objects

NeverSeldomOccasionallyFrequentlyAlways
Uses head movements when visually tracking

NeverSeldomOccasionallyFrequentlyAlways
Sensitive to light

NeverSeldomOccasionallyFrequentlyAlways
Rubs eyes or complains of headaches

NeverSeldomOccasionallyFrequentlyAlways
Distracted by visual input

NeverSeldomOccasionallyFrequentlyAlways
Reverses letter or words

NeverSeldomOccasionallyFrequentlyAlways
Comments on Vision Section
Movement
Fearful of ladders, stairs, teeter-totters, swings

NeverSeldomOccasionallyFrequentlyAlways
Gets motion sickness

NeverSeldomOccasionallyFrequentlyAlways
Dislikes/fearful of trying new movement activities

NeverSeldomOccasionallyFrequentlyAlways
Likes spinning or fast moving activities

NeverSeldomOccasionallyFrequentlyAlways
Does not catch self easily when falls

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

NeverSeldomOccasionallyFrequentlyAlways
Comments on Movement
Muscle Strength and Coordination
Slouches when sitting or standing

NeverSeldomOccasionallyFrequentlyAlways
Tires Easily

NeverSeldomOccasionallyFrequentlyAlways
Seems stronger or weaker than average

NeverSeldomOccasionallyFrequentlyAlways
Has tight or weak grasp

NeverSeldomOccasionallyFrequentlyAlways
Seems accident prone or clumsy

NeverSeldomOccasionallyFrequentlyAlways
Difficulty hopping, skipping, running, jumping

NeverSeldomOccasionallyFrequentlyAlways
Hard time using both hands together

NeverSeldomOccasionallyFrequentlyAlways
Comments on Muscle Strength and Coordination
Please comment on applicable descriptors below
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
Should be Empty:

Sensory Motor Survey

Sounds

Smells

Taste/Texture

Vision

Movement

Muscle Strength and Coordination

Please comment on applicable descriptors below