Primitive Reflex Symptom Screener- UVS

This screener takes about 5–10 minutes and your results will still be scored automatically. This should be filled out by the patient, with parental support if necessary.
Patient Name
Grade
Age
Email
Name of Parent/Guardian (if patient is a minor)
Moro (Exercise: Starfish/Meatball)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Motion Sickness
Allergies/Chronic illness
Frequent Headaches
Fatigues Easily
Stressful/Traumatic birth (mark as 4)
Poor tolerance to change
Anxiety/Nervousness
Mood swings
Challenges communicating feelings
Poor balance and coordination
Poor social skills
Light/Sound sensitivities
Sensitive to unexpected touch
Avoids head position changes (laying down in tub, etc.)
Poor impulse control
Easily overeacts to "little problems"
Easily distracted by surroundings
Poor decision making abilities
Problems with reading comprehension
Struggles with visual tracking (skipping lines, loses place while reading)

Total Moro Score (Flag at 20)
Fear Paralysis Reflex (Exercise: Tapping or Leg Movements)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Low tolerance to stress
Anxiety seemingly unrelated to reality
Hypersensitivity to sound (especially specific frequencies)
Dislike of change or surprises
Selective mutism (failure to speak in specific situations where speaking is expected, despite the ability to speak otherwise)
Holds breath when stressed or afraid
Extreme fear of social embarrassment
Extremely insecure
Clenches fists or curls toes
Avoids eye contact
Sleep struggles (waking at night, falling asleep, etc.)
Has one or more phobias
Physically hides to avoid unpleasant situations
Feels “stuck” in life
Lack of trust in oneself
Tendency to socially isolate and withdraw
Overly clingy or unable to accept/demonstrate affection easily
Fear of work or school
Compulsive traits/OCD
Negativism or defeatist attitude
Episodes of eye flutters, reduced blinking, “staring off into space”
Claustrophobia
Controlling or oppositional behavior
Physical paralysis under stress

FPR Score (Flag at 24)
Babkin Palmomental (Exercise: Rubberband Resistance)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Nail biting or thumb sucking
Difficulty with handwriting, buttons, tying shoes
Sticks out tongue or moves mouth while writing
Sticks out tongue when catching or throwing a ball
Chews on pen caps, pencils, clothing
Tight jaw

Babkin Palmomental Score (Flag at 6)
Palmar Grasp (Exercise: Sequential Finger Tapping)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Awkward pencil grasp
Poor handwriting
Hand fatigue during fine motor tasks (tasks using fingers)
Holding tools or objects excessively tight
Trouble with buttons, zippers, tying shoes, etc.
Holds pencil too tightly or presses too hard
Clumsiness when using the hands independently
Articulation struggles
Difficulty coordinating utensils or gripping too tightly
Difficulty moving individual fingers separately
Difficulty with skipping, hopscotch or jumping rope
Poor hand-eye or foot-eye coordination

Palmar Grasp Score (Flag at 12)
TLR (Exercise: Superman/Banana)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Difficulty with ball-related sports
Auditory processing challenges
Poor organizational skills
Clumsy
Poor posture (seated or standing)
Spatial awareness difficulties
Fatigues easily with arms above head
Fear of heights
Weak core/stability
Poor time awareness
Difficulty maintaining attention
Challenges with skipping, jumping, or balancing games

TLR Score (Flag at 12)
ATNR (Exercise: The Lizard)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Poor handwriting or awkward pencil-holding posture
Eye tracking troubles
Poor crossing over midline (one side of the body to the other)
Lack of hand dominance (ambidextrous)
Right/left confusion
Mixes b’s and d’s when writing or reading
Challenges with reading
Holds pencil too tightly or presses too hard
Difficulty copying from the board
Poor balance/postural stability
Difficulty concentrating
Challenges with math (dyscalculia)
Difficulty with skipping, hopscotch or jumping rope
Poor hand-eye or foot-eye coordination
Clumsy

ATNR Score (Flag at 15)
Spinal Galant (Exercise: Snow Angels)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Often fidgety
Struggles to stay on task
Bed-wetting beyond age 5
Sensitive to specific textures
Reading difficulties
Behaves like having “ants in the pants”
Appears restless
Irritated with clothing or belt on waist
Auditory processing challenges
Poor perseverance
Frequent middle ear infections
Struggles with short term memory

Spinal Galant Score (Flag at 12)
Rooting (Exercise: Cat Whiskers)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Speech or articulation challenges
Drooling or dribbling beyond a typical age
Thumb sucking
Anterior tongue tie at birth (mark as a 2)
Feeding challenges
Sensitive to touch around the mouth

Rooting Score (Flag at 6)
Babinski (Exercise: Toe Pick-Up)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Has a history of toe walking or an awkward walk
Does not like toenails clipped
Has difficulty standing still for long periods of time
Struggles with balancing
Has overly ticklish feet

Babinski Reflex Score (Flag at 6)
Landau (Exercise: Half Superman)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Low muscle tone in the neck, back, and core
Poor posture or a rotated pelvis
Difficulties with coordination between the upper and lower body, such as performing somersaults
Struggles with attention
Disorganized
Struggles to concentrate
Often depressed
Lacks assertiveness
Poor emotional regulation
Struggles to transition between activities
Frequently breaks commitments
Chronic back pain (in adults over 40)
Difficulties with eye movement skills

LANDAU Score (Flag at 13)
STNR (Exercise: Cat/Cow)

Select the number below that best describes the frequency of each symptom.
0 = Never | 1 = Seldom | 2 = Occasionally | 3 = Often | 4 = Always | N/A

Rows	0	1	2	3	4	N/A	Unsure
Lays head on desk when writing
Avoidance of sports
Clumsy
Messy eater
Difficulty copying the board
Struggles with handwriting
Easily distracted
Challenges tuning out background noises
Slouched posture
Challenges with swimming
Struggles with learning to ride a bike

STNR Score (Flag at 12)
This screener was completed by:
If there is a large discrepency between the answers provided by the parent and the patient, please fill out two screeners. One from each perspective.
You're done!
Should be Empty:

Moro (Exercise: Starfish/Meatball)