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Sensory Profile

HomeSensory Profile
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Sensory Profile

Winnie Dunn. PhD., OTR, FAOTA

Caregiver Questionnaire

Child's Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Completed by:(Required)
Service Provider's Name:(Required)
Instructions:

Please check the box that best describes the frequency with which your child does the following behaviors. Please answer all of the statements. If you are unable to comment because you have not observed the behavior or believe that it does not apply to your child, please draw an X through the number for that item. Write any comments at the end of each section.

Use the following key to mark your responses:

ALWAYS - When presented with the opportunity, your child always responds in this manner, 100% of the time

FREQUENTLY - When presented with the opportunity, your child frequently responds in this manner, about 75% of the time

OCCASIONALLY - When presented with the opportunity, your child occasionally responds in this manner, about 50% of the time

SELDOM - When presented with the opportunity, your child seldom responds in this manner, about 25% of the time

NEVER - When presented with the opportunity, your child never responds in this manner, 0% of the time

A. Auditory Processing

1. Responds negatively to unexpected or loud noises (for example, cries or hides at noise from vacuum cleaner, dog barking, hair dryer
1. Frequency(Required)
2. Holds hands over ears to protect ears from sound
2. Frequency(Required)
3. Has trouble completing tasks when the radio is on
3. Frequency(Required)
4. Is distracted or has trouble functioning if there is a lot of noise around
4. Frequency(Required)
5. Can't work with background noise (for example, fan, refrigerator)
5. Frequency(Required)
6. Appears to not hear what you say (for example, does not "tune-in" to what you say, appears to ignore you)
6. Frequency(Required)
7. Doesn't respond when name is called but you know the child's hearing is OK
7. Frequency
8. Enjoys strange noises/seeks to make noise for noise's sake
8. Frequency(Required)

B. Visual Processing

9. Prefers to be in the dark
9. Prefers to be in the dark(Required)
10. Expresses discomfort with or avoids bright lights (for example, hides from sunlight through window in car)
10. Expresses discomfort with or avoids bright lights (for example, hides from sunlight through window in car)(Required)
11. Happy to be in the dark
11. Happy to be in the dark(Required)
12. Becomes frustrated when trying to find objects in competing backgrounds (for example, a cluttered drawer)
12. Becomes frustrated when trying to find objects in competing backgrounds (for example, a cluttered drawer)(Required)
13. Has difficulty putting puzzles together (as compared to same age children)
13. Has difficulty putting puzzles together (as compared to same age children)(Required)
14. Is bothered by bright lights after others have adapted to the light
14. Is bothered by bright lights after others have adapted to the light(Required)
15. Covers eyes or squints to protect eyes from light
15. Covers eyes or squints to protect eyes from light(Required)
16. Looks carefully or intensely at objects/people (for example, stares)
16. Looks carefully or intensely at objects/people (for example, stares)(Required)
17. Has a hard time finding objects in competing backgrounds (for example, shoes in a messy room, favorite toy in the "junk drawer")
17. Has a hard time finding objects in competing backgrounds (for example, shoes in a messy room, favorite toy in the "junk drawer")(Required)

C. Vestibular Processing

18. Becomes anxious or distressed when feet leave the ground
18. Becomes anxious or distressed when feet leave the ground(Required)
19. Dislikes activities where head is upside down (for example, somersaults, roughhousing)
19. Dislikes activities where head is upside down (for example, somersaults, roughhousing)(Required)
20. Avoids playground equipment or moving toys (for example, swing set, merry-go-round)
20. Avoids playground equipment or moving toys (for example, swing set, merry-go-round)(Required)
21. Dislikes riding in a car
21. Dislikes riding in a car(Required)
22. Holds head upright, even when bending over or leaning (for example, maintains a rigid position/posture during activity)
22. Holds head upright, even when bending over or leaning (for example, maintains a rigid position/posture during activity)(Required)
23. Becomes disoriented after bending over sink or table (for example, falls or gets dizzy)
23. Becomes disoriented after bending over sink or table (for example, falls or gets dizzy)(Required)
24. Seeks all kinds of movement and this interferes with daily routines (for example, can't sit still, fidgets)
24. Seeks all kinds of movement and this interferes with daily routines (for example, can't sit still, fidgets)(Required)
25. Seeks out all kinds of movement activities (for example, being whirled by an adult, merry-go-rounds, playground equipment, moving toys)
25. Seeks out all kinds of movement activities (for example, being whirled by an adult, merry-go-rounds, playground equipment, moving toys)(Required)
26. Twirls/spins self frequently throughout the day (for example, likes dizzy feeling)
26. Twirls/spins self frequently throughout the day (for example, likes dizzy feeling)(Required)
27. Rocks unconsciously (for example, while watching TV)
27. Rocks unconsciously (for example, while watching TV)(Required)
28. Rocks in desk/chair/on floor
28. Rocks in desk/chair/on floor(Required)

D. Touch Processing

29. Avoids getting "messy" (for example, in paste, sand, finger paint, glue, tape)
29. Avoids getting "messy" (for example, in paste, sand, finger paint, glue, tape)(Required)
30. Expresses distress during grooming (for example, fights or cries during haircutting, face washing, fingernail cutting)
30. Expresses distress during grooming (for example, fights or cries during haircutting, face washing, fingernail cutting)(Required)
31. Prefers long-sleeved clothing when it is warm or short sleeves when it is cold
31. Prefers long-sleeved clothing when it is warm or short sleeves when it is cold(Required)
32. Expresses discomfort at dental work or toothbrushing (for example, cries or fights)
32. Expresses discomfort at dental work or toothbrushing (for example, cries or fights)(Required)
33. Is sensitive to certain fabrics (for example, is particular about certain clothes or bedsheets)
33. Is sensitive to certain fabrics (for example, is particular about certain clothes or bedsheets)(Required)
34. Becomes irritated by shoes or socks
34. Becomes irritated by shoes or socks(Required)
35. Avoids going barefoot, especially in sand or grass
35. Avoids going barefoot, especially in sand or grass(Required)
36. Reacts emotionally or aggressively to touch
36. Reacts emotionally or aggressively to touch(Required)
37. Withdraws from splashing water
37. Withdraws from splashing water(Required)
38. Has difficulty standing in line or close to other people
38. Has difficulty standing in line or close to other people(Required)
39. Rubs or scratches out a spot that has been touched
39. Rubs or scratches out a spot that has been touched(Required)
40. Touches people and objects to the point of irritating others
40. Touches people and objects to the point of irritating others(Required)
41. Displays unusual need for touching certain toys, surfaces, or textures (for example, constantly touching objects)
41. Displays unusual need for touching certain toys, surfaces, or textures (for example, constantly touching objects)(Required)
42. Decreased awareness of pain and temperature
42. Decreased awareness of pain and temperature(Required)
43. Doesn't seem to notice when someone touches arm or back (for example, unaware)
43. Doesn't seem to notice when someone touches arm or back (for example, unaware)(Required)
44. Avoids wearing shoes; loves to be barefoot
44. Avoids wearing shoes; loves to be barefoot(Required)
45. Touches people and objects
45. Touches people and objects(Required)
46. Doesn't seem to notice when face or hands are messy
46. Doesn't seem to notice when face or hands are messy(Required)

E. Multisensory Processing

47. Gets lost easily (even in familiar places)
47. Gets lost easily (even in familiar places)(Required)
48. Has difficulty paying attention
48. Has difficulty paying attention(Required)
49. Looks away from tasks to notice all actions in the room
49. Looks away from tasks to notice all actions in the room(Required)
50. Seems oblivious within an active environment (for example, unaware of activity)
50. Seems oblivious within an active environment (for example, unaware of activity)(Required)
51. Hangs on people, furniture, or objects even in familiar situations
51. Hangs on people, furniture, or objects even in familiar situations(Required)
52. Walks on toes
52. Walks on toes(Required)
53. Leaves clothes twisted on body
53. Leaves clothes twisted on body(Required)

F. Oral Sensory Processing

54. Gags easily with food textures or food utensils in mouth
54. Gags easily with food textures or food utensils in mouth(Required)
55. Avoids certain tastes or food smells that are typically part of children's diets
55. Avoids certain tastes or food smells that are typically part of children's diets(Required)
56. Will only eat certain tastes
56. Will only eat certain tastes(Required)
57. Limits self to particular food textures/temperatures
57. Limits self to particular food textures/temperatures(Required)
58. Picky eater, especially regarding food textures
58. Picky eater, especially regarding food textures(Required)
59. Routinely smells nonfood objects
59. Routinely smells nonfood objects(Required)
60. Shows strong preference for certain smells
60. Shows strong preference for certain smells(Required)
61. Shows strong preference for certain tastes
61. Shows strong preference for certain tastes(Required)
62. Craves certain foods
62. Craves certain foods(Required)
63. Seeks out certain tastes or smells
63. Seeks out certain tastes or smells(Required)
64. Chews or licks on nonfood objects
64. Chews or licks on nonfood objects(Required)
65. Mouths objects (for example, pencil, hands)
65. Mouths objects (for example, pencil, hands)(Required)

G. Sensory Processing Related to Endurance/Tone

66. Moves stiffly
66. Moves stiffly(Required)
67. Tires easily, especially when standing or holding particular body position
67. Tires easily, especially when standing or holding particular body position(Required)
68. Locks joints (for example, elbows, knees) for stability
68. Locks joints (for example, elbows, knees) for stability(Required)
69. Seems to have weak muscles
69. Seems to have weak muscles(Required)
70. Has a weak grasp
70. Has a weak grasp(Required)
71. Can't lift heavy objects (for example, weak in comparison to same age children)
71. Can't lift heavy objects (for example, weak in comparison to same age children)(Required)
72. Props to support self (even during activity)
72. Props to support self (even during activity)(Required)
73. Poor endurance/tires easily
73. Poor endurance/tires easily(Required)
74. Appears lethargic (for example, has no energy, is sluggish)
74. Appears lethargic (for example, has no energy, is sluggish)(Required)

H. Modulation Related to Body Position and Movement

75. Seems accident-prone
75. Seems accident-prone(Required)
76. Hesitates going up or down curbs or steps (for example, is cautious, stops before moving)
76. Hesitates going up or down curbs or steps (for example, is cautious, stops before moving)(Required)
77. Fears falling or heights
77. Fears falling or heights(Required)
78. Avoids climbing/jumping or avoids bumpy/uneven ground
78. Avoids climbing/jumping or avoids bumpy/uneven ground(Required)
79. Holds onto walls or banisters (for example, clings)
79. Holds onto walls or banisters (for example, clings)(Required)
80. Takes excessive risks during play (for example, climbs high into a tree, jumps off tall furniture)
80. Takes excessive risks during play (for example, climbs high into a tree, jumps off tall furniture)(Required)
81. Takes movement or climbing risks during play that compromise personal safety
81. Takes movement or climbing risks during play that compromise personal safety(Required)
82. Turns whole body to look at you
82. Turns whole body to look at you(Required)
83. Seeks opportunities to fall without regard to personal safety
83. Seeks opportunities to fall without regard to personal safety(Required)
84. Appears to enjoy falling
84. Appears to enjoy falling(Required)

I. Modulation of Movement Affecting Activity Level

85. Spends most of the day in sedentary play (for example, does quiet things)
85. Spends most of the day in sedentary play (for example, does quiet things)(Required)
86. Prefers quiet, sedentary play (for example, watching TV, books, computers)
86. Prefers quiet, sedentary play (for example, watching TV, books, computers)(Required)
87. Seeks sedentary play options
87. Seeks sedentary play options(Required)
88. Prefers sedentary activities
88. Prefers sedentary activities(Required)
89. Becomes overly excitable during movement activity
89. Becomes overly excitable during movement activity(Required)
90. "On the go"
90. "On the go"(Required)
91. Avoids quiet play activities
91. Avoids quiet play activities(Required)

J. Modulation of Sensory Input Affecting Emotional Responses

92. Needs more protection from life than other children (for example, defenselessness physically or emotionally)
92. Needs more protection from life than other children (for example, defenselessness physically or emotionally)(Required)
93. Rigid rituals in personal hygiene
93. Rigid rituals in personal hygiene(Required)
94. Is overly affectionate with others
94. Is overly affectionate with others(Required)
95. Doesn't perceive body language or facial expressions (for example, unable to interpret)
95. Doesn't perceive body language or facial expressions (for example, unable to interpret)(Required)

K. Modulation of Visual Input Affecting Emotional Responses and Activity Level

96. Avoids eye contact
96. Avoids eye contact(Required)
97. Stares intensively at objects or people
97. Stares intensively at objects or people(Required)
98. Watches everyone when they move around the room
98. Watches everyone when they move around the room(Required)
99. Doesn't notice when people come into the room
99. Doesn't notice when people come into the room(Required)

L. Emotional/Social Responses

100. Seems to have difficulty liking self (for example, low self esteem)
100. Seems to have difficulty liking self (for example, low self esteem)(Required)
101. Has trouble "growing up" (for example, reacts immaturely to situations)
101. Has trouble "growing up" (for example, reacts immaturely to situations)(Required)
102. Is sensitive to criticisms
102. Is sensitive to criticisms(Required)
103. Has definite fears (for example, fears are predictable)
103. Has definite fears (for example, fears are predictable)(Required)
104. Seems anxious
104. Seems anxious(Required)
105. Displays excessive emotional outbursts when unsuccessful at a task
105. Displays excessive emotional outbursts when unsuccessful at a task(Required)
106. Expresses feeling like a failure
106. Expresses feeling like a failure(Required)
107. Is stubborn or uncooperative
107. Is stubborn or uncooperative(Required)
108. Has temper tantrums
108. Has temper tantrums(Required)
109. Poor frustration tolerance
109. Poor frustration tolerance(Required)
110. Cries easily
110. Cries easily(Required)
111. Overly serious
111. Overly serious(Required)
112. Has difficulty making friends (for example, does not interact or participate in group play)
112. Has difficulty making friends (for example, does not interact or participate in group play)(Required)
113. Has nightmares
113. Has nightmares(Required)
114. Has fears that interfere with daily routine
114. Has fears that interfere with daily routine(Required)
115. Doesn't have a sense of humor
115. Doesn't have a sense of humor(Required)
116. Doesn't express emotions
116. Doesn't express emotions(Required)

M. Behavioral Outcomes of Sensory Processing

117. Talks self through tasks
117. Talks self through tasks(Required)
118. Writing is illegible
118. Writing is illegible(Required)
119. Has trouble staying between the lines when coloring or when writing
119. Has trouble staying between the lines when coloring or when writing(Required)
120. Uses inefficient ways of doing things (for example, wastes time, moves slowly, does things a harder way than is needed)
120. Uses inefficient ways of doing things (for example, wastes time, moves slowly, does things a harder way than is needed)(Required)
121. Has difficulty tolerating changes in plans and expectations
121. Has difficulty tolerating changes in plans and expectations(Required)
122. Has difficulty tolerating changes in routines
122. Has difficulty tolerating changes in routines(Required)

N. Items Indicating Thresholds for Response

123. Jumps from one activity to another so that it interferes with play
123. Jumps from one activity to another so that it interferes with play(Required)
124. Deliberately smells objects
124. Deliberately smells objects(Required)
125. Does not seem to smell strong odors
125. Does not seem to smell strong odors(Required)