2 SENSORY PROFILE Winnie Dunn, Ph.D., OTR, FAOTA Caregiver Questionnaire (Chile's Name: Birth Date: Date: ‘Completed by: a Relationship to Chie Service Provider's Name: Discipline: Reus | —__ Please check th box that best describes the frequen with which your does the folowing behaviors. lease answer alot he slalements. you are unable to comment because you have not absered the behavior or believe that ‘itdoos not apply to your chid.leaso craw an X through the numbor for that item. Wito any comments atthe end ofeach section. Pease do not wie in the Section Raw Score Total rw. Use the following key to mark your responses: ‘When presented wit the opportuni in this manner, 100% ofthe time, RPTETERIR When presented with the opportunity, your child frequent responds ‘ihe mane sto 7obct ee PBB presented wit the opportunity, your chie occasonaly responds See jn this manner, about 50% of the time. ‘When presented wit the opportunity, your chi seldom responds in this manner, about 25% ofthe time, ‘When presented with the opportunity, your child never responds in this manner, 03 ofthe te. HRS your child evays responds er Copyright © 1998 by The Psychologies! Corporation Al ightsresene, "No prt ofthis publication may be reproduced or ransmited in any form or by ay moans, electronic or dail alain pompy loaner oy namin grandam swan ciate QP TEE ron ocicat Tinbergen peta BSYCHOLOGICA Corporation. Atlarcourt Assessment Company. Pénted in the United Statos of Amerca 13 14 15 16 17 18 19 DABCOE ‘761698089Rep Maree] Ro Responds negatively to unexpected o oud noises (for example cries o ides at ‘ise ftom vacuum cleaner, dog barking aie dryer) Healds hands over ears to protect eas from sound Has trouble completing tasks when the radio is on| Is distracted or has trouble functioning if there isa lat of noise around Can't work with background noise (for example, fan, retigeratr) "Appeal ear what you sy Wor example, dos not "nes to what you 83 appro gnee you) Doesn't respond when name is ealed but you know the cies hearing is OK Enjoys strange ncisos/s00ks to make noise for noieo's sake Section Raw Score Total Paes refers to be inthe dark ‘Expresses discomfort wih or avoids bright lights Wor evapo, dbs from sunlight through window in car) Happy to be ia the dark Becomes fustated when tying lo Thd objects competing backgromds or example, a catord dave) Has difculty puting puzales together (as compared to same age chilren) Is bothered by bright ights ater others have edapted to the light ‘Covers eyes or squits to protect eyes from light Looks carefuly or intensaly at objocte/people (or example stares) Has a ard fine finding objects competing backgrounds Gor example, shoes na messy room, favorit toy inthe “unk drawer’) @ 16]6]@/0) 6 |0| @ 6 ‘Section Raw Score TotalBecomes anvious or distressed when fet leave the ground Disikes activities where head is upside down (fr example, somersaults, roughhousina) ‘Avoids playground equipment or moving toys (or example, swing set, mery-goround) Dislikes riding in car Holds head upright, ven wnen bending aver o leaning (lor example, maintains a ‘rigid postton/posture during activity) Becomes disoriented attr berding over sink or table for example falls or gets dizzy) ‘Seeks allinds of movement and this interferes with daly outines (for example, cant sit sti, fdgets) ‘Seoks out al kinds of movement activites (for example, being whirled by adult, mary-go-ounds, playground equipment, moving toys) “Twls/spins sel frequently throughout he day for example, kes dizy teeing) Rocks uncansciously (or example, while watching TV) Ub] db fd] d ded |b Comments Rocks in desk/chairon floor Section Raw Score Totalxi Acids geting “messy” (or example, in paste, sand, finger paint, que, tape) Expresses distress during grooming (or example, Fights o oes during harcuting, face washing fingernail euting) Prefers long-sleved clothing when i is warm of shor sleeves when itis cold Expresses discomfort at dental work or toothbrushing (for example, cries or Fights) ls senstve to certain fabrics (or example, is particular about cetan clothes or bedsheots) Becomes inated by shows or socks Avoids going bartoot, especially in sand or grass | Reacts emosonaly or aggressively to touch Withdraws from splashing water Has difiuly standing in ine or close to other people Fubs or soratches out a spot that has been touched ERIE IER) ARIE | J Touches people and objects tothe point of tating others Displays unusual need fr touching cortan toys, surfaces, or textures (or example, constantly touching objects) Decreased awareness of pan and temperature & Doesn't seem to notice when someone touches arm or back (or example, unaware) ‘Acids wearing shoes; loves to be barefoot ‘Touches people and objects Doesn't seem to notice when face or hands are messy RII. Section Raw Score Total See Gets lost easily (even in familar places) Has dificuty paying attention Looks away from tasks to notice al actions in the room ‘Seems oblivious within an active environment (for erample, unaware of att) Hangs on people, furitue, or objects even in familia situations ‘Walks on toes Bt see coting wines on boy Section Raw Score TotalGags easiy with food textures or food utenssin mouth LU, Avoids certain tastes or food smells that ar typically pat of chidren’s lets Willony eat certain tastes (ist: J Limits sel to particular food tertues/temperatures (ist: Picky eater, especialy regaring food textures Routinely smels nonfoad objects ‘Shows strong preference for certain emai (it: J Shows strang preference for certain tastes (st Craves contain foods (is: J ) ‘Seeks out contain tastes or smell 610/016 )6 0 |12316 1G | ‘Chews or licks on nonfood objects Comments Mouths objects (or example, ponci, hands) Section Raw Score Total Moves stify UA Ties easiy especially when standing or hoeing particular body poston Locks joints (for example, elbows, ees) for stability ‘Seams to have weak muscles Has a weak grasp Can't it heavy objects for example, weak in comparison to same age children) Props to support se (even during aotvity) Poor endurancelres easly Ld >t ]>tl>tl>#]>t tot ‘Appears lethargic (for example, has no energy. is uggish) Comments Section Raw Score TotalSooms accidentprone estates going up or down curbs or stops (or example, is cautious, stops before moving) Fears fling or heights ‘Aids cimbing/umping or avoids bumpyluneven ground Holds onto walls or barsters (fr example, cings) Takes excessive risks during play (or example, climbs high nto a tree, jumps off tall future) “Takes movement or climbing risks during play that compromise personal safety Turns whole body t ook at you ‘Seeks opportunities to fall without regard to personal safely P+>4] LL] L]L)b |i} @)3 i i ‘Appears to ory fling ‘Section Raw Score Total Mirren) ‘Spends most ofthe day in sedentary pay (lr example, does quiet things) Prefers quit, sedentary play lor example, watching TV, books, computers) Sooks sedentary play options Prefers sodontary activites ‘Becomes ovety excitable during movement actly “On he go" Avid uit pla activites Section Raw Seore Total Commaris o | "Needs more protection from le than oer cron (for sample, defenseless i physical or emotional & (ef igi uaa in peaorl hygiene © | {Is overly affectionate with others ° |# ‘Doesnt perceive body language r face expressions (ox example, unable o interpre) Section Raw Score Total CommentsK Modulation of Visual Input Affecting Emotional Responses and Activity Level ‘Avoids eye contact ‘Stares intensively at objects or people ‘Watches everyone when they move round the room ‘Dosse't notice when people come into the room Section Raw Score Total Ean ensan ncaa cou eens ‘Seems to have dficuly liking self (or example, low seltesteer) Has trouble “growing up" (lor example reacts immaturey to stations) Is sensitive to citcisms Has dante fears fr examplo, fears are predictable) ‘Seems ancous Displays excessive emotional oubursts when unsuccessful ata task Expresses footing the a fare Is stubborn or uncooperative Has temper tantrums Por frustration tolorance Cies easily Overy serious Has dificuly making tends (or example, does not ntaract or participate in group play) Has nightmares Has fears that interfere with dally routine Doesn't have a sense of humor B}GB}G]G}G}B]B|G]B|B|G|G]G]G|3/a/a Doesn't express emations Section Raw Score TotalItem FAP | Tats so through tasks H18)| Writing is legible 1198) Has trouble staying between the Fnes when coloring or when writing Uses inefficient ways of doing things Vor example, wastes time, moves Slowly, B/G] 3 /6/@\s eu _Goes things a harder way than is needed) | #21 | Has citeuty tteating changesin plans and expectations Has cut toeraing changes in routines Section Raw Score Total ‘Comments Item So ee * BA rrp rom ono acy o another so that titres wih lay S [HFA] dotvertay svete objects S|] 0025 nat seem o onal strong odors Section Raw Score Total Comments f a z FOR OFFICE USE ONLY eee 2D | taastory 1 S_| Visual 2 HK | Aeivity level 3 S | Teste/Smet 4 XK _ | Body Position 5 i = 1S6N 076-1636-05-9 | 78076 1638056)