| SENSORY PROFILE ‘Winnie Dunn, Ph.D., OTR, FAOTA Caregiver Questionnaire Chiles Name = ith Date Date: Complete by Relationship to Chil: . Senvce Provider's Name: _ Discipine ‘Prease check the hor that best desaibes the frequency with which your child ‘dove the following behaviors. Please answe: ll ofthe statements. you are ‘unable to conment because you nave not observed the behavior or bolve that itdoee not apply to you" chi, please draw an X through the number for that item, White any comments atthe end of each section, Pease do not write the ‘Section Raw Score Total ron, Use the following key to mark your responses: ‘When presente wth the opportuity, your child always responds inthis manner, 100% ofthe time, ae ‘When presented with tho opportunity, your chi requently responds LaenAMIAMIM i his rannor, about 75% ofthe te. : ne RAB hon presonod wth the opportunity, your cid occasionally responds ReeaaiANNR in hs mannoy, about 50% of he tie, ey "When presented with the opportunity, your chid eeldom responds z inthis manner, about 25% ofthe tims. ‘When presented withthe opportunily, your child never responds in this manner, 00 ofthe tim. nin PEARSON @PsychCorp aE: ISBN O7b-3638-05-6 Copyright © 1999 NCS Pearson, Inc. Al rights reserved. 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Printed in the Unites States of Amerie. 25 27 28 29.30 ABCDE sl7e076 Mlesa056)Responds negatively to unexpected or loud noises (or example, cies or hides at DF ros ton cu dearer eg bting ha ye 2 |e Hol hard everest roe! ears om sound 9 {kt Has trouble completing taske when the radio is on 2 |x is acd or has voubl finan hr aot of ce wound eS > Topoars to ot ear wha you sy or exam, doesnot une” t what you iareepa Bigeye 9 |n Docent respond hen rane scaled but you now he cies heaing ie OK 9 |# ioe strange ribs/soak to make nde fo rcs sake ‘eclon Raw Score Total oo ® ft refers to bein the dark on Eres dm wines De oar Fon Sie Happy Bein to dirk oe Secs Thie nig nd coe cot OTS @ ile Has dificult puting puzzles together (as compared to same age children) oie is bothered by bight ais air ters ave adapted othe igh @ iL Covers es ost fo protect ees From ae © /F Tooke carly or Finely af objecapeople (or ean tare) © PE ence ee ‘Section Raw Score Total onan~ a Me =5 Becomes aniou ocsvessed when eatleave he ground > Disko activo whore head i upside down (or eampie,somerauts, oughhousig) > ‘vids playground equipment or meving os Vor example swing set mer} goround) = Disks ing in a cr as lds heed upright ren when bending over or laring fo example, marane a ‘ig postonposture ding acy) > Becomes disoriented afr bending ove srk o tbl for ramp feo goto di) a Seeks al rds of mavonent and his ores wih Gly roares (er eanpe, can't tie) > Seeks out al kins of movenert aces (or example, bang whvod by edu, enn grounds, playground ecaipment mov oy) > Twitepne el equenty threughout the day for exampl, ha diy oong) sre hos dan ooing > |e Focks unconsciously or ramp wile watching TV) > |e | as | ects in dostihatvon toor ‘Seation Raw Score Total Commenta ioe ‘Avoids geting “‘mesey” (or example, in past, sand, ger pain, ve, tape) Mh igresses dtvess during grooring for exanpl, fights cries during hakcutng, ace washing fngemalcuting) Prefers longrsteeved clothing when iis warm or shor slaoves wien its cold Expresses dscomiort at dental work or toothbrushing (fr example, cies or fight) Is sensitiv to certain fabrics (or example is particular about certain clathes or bedsheots) Becomes initated by shoes or socks ‘Aoi going barefoot, especially in sand or grass Reacts emotionally or aggressively to touch ‘Withdraws from splashing wetor Has difcaty standing ine or close to other people Rubs or scratches outa spot that has been touched Toschos paople and objects to the point ofitatng ators Displays unusual need for touching cera toys, surfaces, or tenures (fo example, constant toucring objects) Decreased awareness of pain and temperature Doesn't seem to nace when someone touches am or back (or example, unaware) ‘Avoids wearing shoes; loves to be barefoot Touches people and objects s{z{z{jz] 2 fzfe|e[efe[e|refe|e|e] Doesnt seem to notice when face or hands re messy Com 3 o ‘Section Raw Score Total Gets lost easly (oven in fair places) Has cific paying attention Locks away fom tasks to nate al actions in the room ‘Seems obvious within an active enviroament fr example, unaware of actin) Hangs on people future, or abject even in fair situations Walks on tes | lab Pfolelale fl e|e [sie i i Leaves doting twisted on body Seaton Raw Score Toal [IGags easy with food tetwes or food utenss in mouth ‘Aids certin tastes or food smels that are typically part of chicren’s iets Wil ont eat corti taste (et: Flelel Limits sl to partcular food textures/temperatures (it ky cator, aspect garding food textures {| Routinely smels nonfood objects || Shows sting preference for certain amels (it ‘Shows strong profarence for oortan tases (it: CCraves certain foods ist = || Seeks aut certain tastes or smal it. [| Chews or leks on ronfood abjects| 1161610) G |G |)10 |G |e z/z/z/z/2/z/=/-/- Mouths abject fo examgla, pene, hands) Section Raw Score Total Comment Moves stil Ml “Tres easiy, especialy when standing o holding partcular body position Locks joints (or example, elbows, knees) fr stably ‘Seems to have weak muscles 0 | Has a weak grasp Can't it heavy objects (lor example, weekin comparison to sama age cides) Props to support self even during actviy) Poor endurancelires easly VIL lott ot fot lt] tat z{z(z/=|/=/z Appears lethargic (or example, has no ene, is Suggish) ‘Section Raw Score Total Comments‘Spends mast ofthe day in sedentary play (or example, does quit things) ° ® => > = > = > Tire whale Bed ook tou t ook oppor to fal without regard o parson aly cd Aopear to ne ling ‘Section Raw Score Total ¢ Comments Prefers quiet, sedentary play (for xamle, watching TV, books, computes) ‘Sooke sedentary ple options Prefers sedentary activities ‘Becomes avery exstale during movement sctvity “On the go" Sele] LL] Selo ‘Acids quiet play actos Section Raw Score Total | Cones S Nads mar protectin fom ethan ae chiden Gor example defenseless phyicaly or onctonaly) & Rigel uals personal yin o Tovey afoconao with oes oO Doesn't perceive body language or facial expressions (for example, unable to interpret) Section Raw Score Tos! [INT UI DL CommentsLouch ree Lt ‘Avoids eye contact ‘Stars intensely at objects or people Walchos eveyone whon thoy move around the room Doesn't atice when people come into the roam Seaton Raw Score Total ESne enero eee Wy, ‘Seems to have dificult Skng sl (ar example, ow sel-eteem) Has trove “growing up’ (or example, reacts immatuely to stuatons) Is sensitive to criticisms Has deine fears (or example, fears are peoditabie) Seems anxious | Disclays excessive emotional outbursts when unsuccessul ata task Expresses fosing Ike a flire Is stubboin or uncooperative Has temper tantrums: Poor fustiatin tolerance ries easy Overy serious Hae aly making tends for example, does rat reac er arte in eu ay [a3 | Has rignimares SFGAR] Has oars tat ntrer wih diy routine Doesnt have a sense of humor 8} B| G| G| G|G|G]G/G| G/B} G)G}G/G/a/a Doesnt express emotions ‘Section Raw Score Total ; iWing siege Has rouble staying between the ines when coloring or when writing Uses insicint ways of doing things lor example, wastes me, moves slowly, cles things a harder way than is needed) Hs dificulytleraing changes in plane and expectations BIG] 3 /0/e|9} Hee dificult tolerating changes in routines ‘Section Raw Score Total oe Sumas I ems Indicating Thresholds for Response x GB] ump rom ove acy to anche that ire wh ly > | faa8 | Dotiberately smote objects [A | 25 | 000 not ceo el ctor ow Secon Raw Score Toll =2 Comer FOR OFFICE USE ONLY THRESHOLD KEY