MBR i-Go Liability Waiver / Rental Agreement

Sensory Motor Checklist
Clinician *
Child's Name *

First Name Last Name
Parent's Name *

First Name Last Name
1 NEVER | 2 OCCASIONALLY (1-2x month) | 3 SOMETIMES (weekly) | 4 FREQUENTLY(2-3x week) | 5 ALWAYS (daily)

AUDITORY *

	1	2	3	4	5
responds negatively to loud, unexpected noises(covers ears)
is distracted by background noises (refrigerator, fan)
seems oblivious within an active environment
experiences discomfort from hair cutting
overly aware of sounds
has/had frequent ear infections
difficulty with speech and annunciation
fails to listen to or pay attention to what is said
frequently requires repeated instructions as if to buy them time to understand the directive
talks excessively, which can interfere with listening

PROPRIOCEPTIVE *

	1	2	3	4	5
has difficulty learning new motor skills like skipping, hopping, jumping jacks, shoe tying
appears clumsy, stumbles often, crashes into door frames/furniture
has difficulty falling asleep
frequently hits, shoves, or knocks
picks or bites finger nails, chews on things, touches lips
seems generally weak
seems unaware of cuts and bruises
difficulty learning sequential tasks (i.e shoe tying)
too forceful with animals
fidgets, fiddle with things all the time
has poor endurance, tires easily
appears to enjoy falling or crashing to the floor
walks on toes
seeks out crashing opportunities
holds onto banisters, people, furniture when navigating familiar space

TACTILE *

	1	2	3	4	5
displays heightened need for touching objects
avoids touching objects/getting messy
excessively ticklish
overheats easily
dislikes showers, baths, or getting splashed
limited wardrobe
limited food choices
wipes hands frequently
has difficulty standing in line or close to others
doesn’t recognize when hands/mouth dirty

VESTIBULAR *

	1	2	3	4	5
seeks constant movement that interferes with daily routine
gets dizzy or car-sick easily
fearful of heights
avoids reaching across body for items
takes excessive risks during play
frequently tips chair back on two legs
requires excessive movement
loses balance easily
slumps when sitting
hesitates going up or down curbs or steps

VISUAL *

	1	2	3	4	5
distressed by bright lights
difficulty telling time on an analog clock
avoids eye contact
does not consistently recognize shapes, letters, numbers
has difficulty putting puzzles together
prefers to be in the dark
has difficulty tracking with eyes
loses balance easily
slumps when sitting
often squints when looking at things/covers one eye

OTHER: *

	1	2	3	4	5
distressed by odors or smells
prefers foods with very strong tastes
difficult to wake in morning
chronic, irregular, bowel + bladder regulation
unpredictable sleep/wake cycle
often reverse numbers/letters or process backwards
over sensitive to sensations of hunger and thirst
under sensitive to sensations of hunger and thirst
has difficulty making friends
is easily frustrated by new or challenging tasks
gets “stuck” on tasks and has difficulty transitioning from preferred tasks

Should be Empty: