Caregiver Questionnaire 7 to 35 months 4 wee yey [ODDLER Winnie Dunn, PhD, OTR, FAOTA | mba IL L ‘Che Fit Nam Ch dee Name: ‘oh LastName. Name an ‘his Prefered Name fret ram above: ‘Gender Male Female ith Dae: Examine/Sevce Provides Name ‘SxaminalSenice Proves Pasion: Comeited by/Caregers Name: Carers Faatoneip to Chis Name o Daycare Cater: Was tis cil bor promaturi? Ves CINo yes, by how many wooks? In what ordor was your eid ber nation to singe flor example etch, Sachi, ee lon Ghd Cat 2nd Cae Ce Cth CO Ober Have there been mor than tee chien betesn te ages ft trough 18 yearsfvng in yourhousohol uring the past mone? ves CIN “Ts pages tht fli conan saterans tha dese hw chan may act Passat each ase ands te ‘on hat best escrbes Pow cen your child shows hase eters, less ark ne coon eer sateen ‘Use tec gudelies to mark your erponees: “nen presented withthe oppertanty, my ci. respondsin his manner Almost Always [BD Fre othe ir respons in hs manner requont (5% fhe ne responds inthis manner Hal the Tne 50% of he i). respons ints manner Oceaslonaly (25% oh tne. responds in ths manner Almost Never (10% or sso etn you are unatio answer bacasse you have not observed he behavior or belive | tat does nt apt our el, plese check Dace Not Ap. er Sires eater ere nee Oran Sapna smomam ameriamertatenm cnr, Seana mera {prin hero, Par a Sean rie eases hte er aeons} «JMy cha. ter sods out ty corto or an, ‘acts na way thal eee with fay choos and lr rests playng ang oer chin. takes longer than same-aged cron o respond to question or actions. eter rom tua. hasan urgretabi snoping pate. hasan ure eat ptt, ‘easly awakened. rissos oy cortct wih me cing every teacons I sans mre suns. I GENERAL Processing Comments yeh. ony pays ation #1 speak lucy, 12 ony pays ateton whan tuzh my chi (anhearng ic OX. ‘tuts easy at curd compared sari aped chien for exe, og baking, keen shou | 14 cloaked in ciy stinas. 15 gore sounds, ncudng my wis, 18 becomes upset o esto escape ram nly stings. 7_takes along tie to respond ta own name, AUDITORY Processing Comments 1 Tirooo1en sowory Pron 2Myc. Z ‘ros ooeng at moving or siming ct (or xp cling fans, os wih esl, | 10 ero lng ahi boot | 21s sraced 0 TV o carpal srers wi as pci, br exo rach py ixtos bight or unreal gt for exarpe, whan moving em niet oma) 22 share by bight ight for example Fides fo sui trogh ar window, 28_ temo bothered by big ight han ober sane-aged cider. Bhs bray colored toys nay 25 fas tospond to sefin their” VISUAL Procstsing Comments ay os. becomes upton hang nase. 2 ross bing ccs \cussat whan moving aman spaces with very ier temperatures lor xarel, co, ware, ‘wtheraws tom contact wth ough cal, e sickysutaces for exam, pe cours). t bumps ito tangs, fing to note objects pele nthe way. ll tlting or sets ting coting on, {crop ssing ding bath evi ti 4 _boconas upset own ating han, o ace we messy becomes arcus when walking or rag on cern surtaoas or exarele (ass sand, capel, eh” 35 _witdaws tom unxpeciea tueh” o ‘TOUCH Processing Comments TOOOLER Serer Pte 25H 3My i. - ‘roy pyscal acti Yor example, bouncing, bring Nel vp gh thee ‘ros teats for oxaple, xing, ostng,car ree). takes mover or ling ks } cers up when paced on he back for axe at changing as) vos acorn Fury. sese si MOVEMENT Raw S207 ‘taza when moved wound for xanpl, waking round, when bela handed vert ance peor” Seatekt Recatag ostenakee ———— S ty ch. ran a rsh fal bua ow food cies. 098, os cing to cat se 908 on foods or ir AT holds food ehests bles svalowrg 2 « 4 _sefers netted for exam, root ene) - ce © 4a tcuty weanng to chun fos, ‘ORAL SENSORY Raw Score (ORAL SENSORY Processing Comments 4 BBrovoten soray Pet?Sn My en. - has taper trun, ieatngy. stay calm only whan blog Pa Issey or itd |e boteed by row stings. cores so upset nna stings t's hard focal down, eoeeg 3h [BEHAVIORAL Raw Sao BEHAVIORAL Responses Comments FOR OFFICE USE ONLY TODDLER Senor Pi 2 5Notes {6 BHroooten soney Pete 2——— roe scon > nee BEY (QDDLER SCORE SUMMARY Quadrant Grid Please read careful the dete henc-scom habuctone in chapter 4 ofthe Sensory Pot 2 Uso" "Manual. Taner the am ra sare Fam the CargierGuostonnare, A each cours fe sor 10 (et the Quarart Raw Sooe Tas. ij enon Suto ‘TODDLER Seren Prste 23H TSummary Scores ‘Water ach Quacrant Paw Score Total om the Quant gs othe conesponding Quant Few Score Total boy. “Ten, ans the section Faw Score Totals rom te Caregiver Cuestionare tothe coresponcng Raw Score Toa box. Pot hese tas by making an Xin the appepiat lsacaon clu (Lee Than Oter, Mare Than Other, {ust Uke the Mary of Others The Normal Curve and Sensory Profile 2 Classification System ‘Soares one stand eis or mare rm the an ae xoested as More Tan Oso Less Than “4 Ohers rapectney Soo two stnatdevatere, eT || Corman om fhe ean ar expressed as Much More 20 “ha iao'6 which cil ibrar by senso nut Ach th a Nich Hee Than hes so tne ten moves oy fm sera np at irate er ‘Thedareeto wich cll des sary Re ci wih Mh Tan Ors cs pata acm encrypt tage anes. ‘ra degaeto whch cid metas anny. Ach hos Hee Than Oe son he pater eae seu nulla grr thon TOODLER Sener Pte 2d