Sensory Assessment - Parent/Caregiver

Concerns
Instructions:

This questionnaire is designed to help gather information from the parent(s) or primary caregiver(s) of the child being evaluated. Please provide detailed descriptions and examples for each question.
Describe your major concerns about your child at the present time.
Relationships
Who lives with your child at home? How does your child relate to different family members?
What other children does your child spend time with? How old are they? What types of activities do they do together? How do they get along?
Does your child prefer to spend time alone or with others?
Activities and interests
5. What activities does your child like to spend the most time doing? Describe your child's special skills or areas of particular interest in as much detail as possible.

Sensory behaviors

Describe your child's responses to sensory input and changes in his/her surroundings, including any preferences and aversions.
Food
What types of food does your child prefer?
What types of food does your child dislike?
If your child is bothered by specific foods, have you noticed what is bothersome, for example. specific textures, food touching other food on the plate, or food mixed together?
Does your child follow any dietary restrictions? Describe any specific changes in mood or behavior you've noticed since putting the dietary restrictions in place.

Clothing
Are there types of clothing your child prefers?
Is your child bothered by clothing, for example, tags, seams in socks, long sleeves, tight or loose clothing, or types of material?
Tactile
What types of touch does your child seek out, for example. deep-pressure input, light touch, avoids touch?
Does your child frequently touch or hold objects?
Does your child pick at his/her skin or hair, or place his/her fingers, hair, or other objects in his/her mouth?

Visual details
Does your child seem to notice or comment on visual details that others do not pay attention to? Can you give an example?
How does your child react to changes in visual details, for example, if something is moved or rearranged in his/her room or elsewhere?
Noises
What types of noises bother your child? How does he/she react?
What types of noises does your child seek out?
Smells
Are there particular smells that your child dislikes or comments on as being bothersome?
Does your child ever explore objects by smelting them?

Sleep patterns
What is your child's bedtime routine?
Does your child sleep through the night?
Body boundaries
Does your child become upset when he/she perceives others to be standing too close or entering his/her personal space?
Does your child show a lack of awareness of personal space by standing too close or entering the personal space of others?

Crowded places
How does your child react in crowded places?
Transition times and changes in routine
How does your child react to transition times, such as shifting away from his/her preferred activity to an activity you are directing your child to do?
How does your child react to changes in routines?
Does your child do better when you prepare him/her for changes in advance?
Do you ever prepare your child for a change in routine by presenting it in a written or visual format, such as a calendar or list?
Response to pain
How does your child respond when he/she is hurt or has minor bumps or scrapes?

Emotions - anger/frustration

Describe how your child manages anger and frustration.
What situations trigger anger or agitation in your child?
How does your child express anger or agitation?
What helps your child to calm down when angered or agitated?
Emotions - fear/anxiety
What fears or anxieties, if any, does your child display?

Medications
Is your child taking any medications?
Describe the type and purpose of each medication.
How long has your child been taking each medication?
What changes in your child's behavior have you noticed since your child began taking each medication?
Developmental milestones

Describe your child's developmental milestones.
Was there anything notable in your child's birth history?
Did your child experience any delays in the areas of walking, talking, or toilet-training?
Did your child receive any early childhood interventions, such as speech therapy, occupational therapy. or physical therapy? If so. what therapy services were received?
Has your child had any physical health conditions or major accidents or injuries? If so, what type of treatment did he/she receive?

School experience
Describe your child's school experience. What interventions or supports have worked well? What changes would you like to see put into place for your child?
Past experience
Current

Current understanding of autism spectrum differences
What have you read or learned about autism spectrum disorder? What are your thoughts about autism spectrum differences in relation to your child?
Evaluation history
Describe any previous testing and the results.
Family history
Is there anyone in your immediate or extended family who has learning, social, or other challenges?
Three words/qualities to describe child
What three words or qualities would best describe your child?
Closing questions
Is there anything else you would like us to know about your child?
What do you hope to gain from this evaluation?
Do you have any specific questions about the evaluation process?
Additional notes
Date Completed

MonthDayYear
Date
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Demographic Information