Moulsham Grange Children’s Centre

Moulsham Street
Chelmsford
Essex CM2 9AH
Tel : 01245 546300
Fax : 01245 546301

SENSORY QUESTIONNAIRE FOR PARENTS

Name: D.O.B.

Address: School:

Tel No: Date:

Parent’s/Guardian’s Name: ……………………………………………………………….....

The purpose of asking you to complete this questionnaire is to gather further

information in preparation for your sensory assessment by an Occupational
Therapist. Please give as much information as you are able to and indicate if there
was a problem in the past that has now resolved itself. Thank you for your help.

What do you feel are your child’s strengths?

Please give a brief summary of your child’s birth history e.g. any complications.

Responses to touch: Does your child?

React aggressively to or is overly irritated by unexpected touch Yes/No

Touch objects or people excessively Yes/No

Respond to pain as you expect Yes/No

How concerned are you about Response to Touch:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

Page1

Comments:
Does your child have difficulty coping with any of the following self care routines?

Please Tick

Hair washing, cutting Face washing,

Nail Cutting Teeth brushing
and brushing bathing, showering

Eating, Refuses Dressing, e.g. feel of

certain textures or labels or texture of
gags on food fabric

How concerned are you about willingness to engage in these activities:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

Comments:

Responses to Sound and Noise: Does your Child?

Over react to any types of sound be it volume, pitch or tone Yes/No

Cover their ears to protect them from any particular sounds Yes/No

Make repeated noises themselves to help them cope better Yes/No

with sound

Become easily distracted by noise Yes/No

How concerned are you about Response to Sound and Noise:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

Page2
Comments:

Responses to Smells: Does your child?

Over react to any particular smell or become irritated by them Yes/No

Always smell food before tasting it Yes/No

Regularly smell objects Yes/No

Rarely notice when a strong smell is present Yes/No

How concerned are you about Response to Smell:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

Comments:

Response to Taste: Is your child?

A fussy/picky eater Yes/No

Able to tolerate a wide variety of foods Yes/No

Prepared to try new foods Yes/No

Does your child?

Prefer very strong flavours Yes/No

Page2

Act as if all food tastes the same Yes/No

How concerned are you about Response to Taste:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

Comments:

Response to Visual Information: Does your child?

Over react to bright light e.g. sunlight or supermarket lights Yes/No

Become easily distracted by visual information Yes/No

Blink frequently Yes/No

Find it difficult to find a favourite toy or object when it is Yes/No

partially hidden by other items or the items are similar in colour.

Have difficulty with unusual visual environments e.g. brightly Yes/No

coloured rooms or dimly lit ones.

Close one eye and/or tip their head back when looking at someone Yes/No
or something.

Have difficulty following objects with their eyes Yes/No

Lose their place frequently when reading Yes/No

How concerned are you about Response to Visual Information:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

Comments:
Page2
Response to Movement and sense of Proprioception: Does your child?

Seek out an excessive amount of movement e.g. continually Yes/No

“on the go”

“Forget” to save themselves when falling Yes/No

Avoid movement opportunities Yes/No

Tire easily or seem to have weak muscles Yes/No

Easily become dizzy Yes/No

Appear fearful or anxious when feet are off the ground Yes/No

Rock when sitting Yes/No

Like to spin self excessively or actively seeks out games which Yes/No
involve spinning, whirling or being upside down

Find calming self after movement experiences is difficult Yes/No

Enjoy playing on swings and roundabouts Yes/No

Find it difficult to judge the force at which he/she does something Yes/No
and may end up unintentionally breaking toys or hurting others

Seek activities such as pushing, pulling, dragging, lifting or jumping Yes/No

Like to frequently crash to ground Yes/No

Find it difficult to sit upright, or choose to lie down instead Yes/No

Grind their teeth Yes/No

Chew on non-food items Yes/No

Grasp items so tightly that it is difficult to use the object or the Yes/No
object gets broken

Grasp items so loosely that it is difficult to use objects Yes/No

Like giving and/or receiving tight bear hugs. Yes/No

How concerned are you about Response to Movement and sense of Proprioception:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

Page2
Please describe your child’s general behaviour and what your concerns are. Please also
describe what seems to calm your child, if known.

How concerned are you about child’s general behaviour:

Not at All 1 2 3 4 5 6 7 8 Very Concerned

What support do you feel you need? And what do you hope to gain from your child being
assessed?

I/We consent to my child being assessed by the therapist

Signed…………………………………………….Dated……………………………
Parent/Guardian
Page2