Sensory Integration Dysfunction/
Sensory Processing Disorder

Does your child have Sensory Processing Disorder?

**For each question click the box next to each sentence that describes your child. If more than half of the boxes in a question are checked, click the "Yes" option. If less than half of the boxes in a question are checked, click the "No" option.

Please print when done.

1.    Does your child have sensitivity to touch?

Did not find touch calming or enjoyable as an infant.

Is more irritated than children their own age by a shampoo or face wash.

Does not like having his/her hair cut or nails clipped.

Is particular about clothing textures.

Is picky about clothing (i.e., uncomfortable with collars, labels, socks, coats or hats; only likes loose clothing).

Dislikes long sleeves or pants; favors minimal clothing.

Favors long sleeves and pants even in hot conditions.

Tries to escape messy activities for example: finger paints, play dough, mud, cooking, etc.

Overreacts (or) under reacts to physically painful experiences.

Withdraws from group activities, or bumps and pushes in groups; is agitated in close settings.

Yes    No

2.    Does your child like spinning or fast-moving activities at home or on the playground, possibly with little or no dizziness?

Enjoys swinging very high and fast or for long periods of time.

Rides the merry-go-round frequently.

Enjoys bouncing on furniture, using a rocking chair, or being turned in a swivel chair.

Likes being upside down (feet up, head down).

Likes games where eyes are shut (i.e. Bandana or bag over head).

Enjoys fast and spinning amusement park rides.

Yes   No

3.    Does your child show anxiety towards activities involving fast movement or movement of the body through space?

Refrains from using swings or slides or uses them with caution.

Dislikes riding seesaws or going up and down escalators.

Is hesitant about heights and climbing.

Likes movement that he/she initiates but doesn't like for others to move him/her, especially if the movement is unexpected

Dislikes or has difficulty trying and learning new movement activities.

Has trouble climbing or descending stairs or hills.

Is likely to get motion sickness in a car, airplane, or elevator.

Yes  No

4.    Does your child have strange sensitivities to smell?

Has a hard time identifying items by their smell.

Is likely to complain that fairly normal smells are unpleasant.

Is likely to ignore unpleasant smells when they are present.

Yes  No

5.    Does your child have sensitivity to noise; for example, covering their ears when others are not bothered by particular sounds?

Yes  No

6.    Have you ever had concerns about your child's hearing?

Yes   No

7.    Have you ever had concerns about your child's speech or language skills?

Yes   No

8.    Have you ever had concerns about your child's eyesight/vision?

Yes   No

9.    Does your child have muscle weakness or a loose body build compared to other children?

Uses a loose grasp on objects (i.e. pencil, spoon).

Gets tired easily during physical activities or outings.

Has trouble twisting knobs or handles that need some pressure.

Usually slumps in a chair.

Child doesn't feel firm when you lift them up or when you move their extremities to get them dressed.

Yes   No

10.    Does your child easily position their body to effectively get dressed; for example, putting arms in sleeves, or toes in socks?

Yes   No

11.    Do you think your child ( age 4 and up) has already made a hand preference when using a crayon, marker, or pencil?

Yes   No

12.    Does your child automatically take part in physically active situations, such as running, jumping, and use of large play equipment?

Yes   No

13.    Does your child automatically search for activities manipulating small objects?

Likes building with blocks, Legos, or Duplos.

Likes doing arts and crafts with small beads, buttons, etc.

Yes   No

14.    Does your child automatically seek out activities using crayons, markers, pencils, scissors, etc.?

Yes   No

15.    Do you think your child  has a sufficient attention span towards activities he/she enjoys?

Yes   No

16.    Is your child likely to become restless during times that require quiet concentration?

Yes   No

17.    Has your child had trouble adjusting to sleep patterns?

Took longer than most infants to sleep through the night.

Had colic as a baby.

Didn't take naps or took shorter naps than most children.

Has trouble falling asleep.

Doesn't always sleep through the night.

Yes   No

18.    Has your child ever experienced any of the following?

Several ear infections

Allergies

A serious illness or surgery

Yes   No

Please print when done.

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