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  • Sensory Profile - Caregiver (3-14.11yr)

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    Sensory Profile_caregiver (3-14.11yr)

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    108 views8 pages

    Sensory Profile - Caregiver (3-14.11yr)

    Uploaded by

    Ferris

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 8
    Caregiver Questionnaire C Ray ee CHILD @o ~ Winnie Dunn, PhD, OTR, FAOTA, Childs First Name: Chile's Midalo Name: Child's Last Name: I Nab: Child's Proferred Name ft ctforot from above): Gonder: Malo CiFemale Birth Date; Tost Date: Examiner/Service Provider's Name: Examiner/Service Provider's Profession: Completed by/Caregiver's Name: Caregiver's Relationstip to Child: Name of School/Daycare Center: ‘School Grade/Level: In what order was your child born in relation to siblings (for example, tst child, rd child, ete)? Doniy Child Ci1st Cand Card Cath Csth 5 other Have there been more than three children between the ages of birth through 18 years living in your household during the past 12 months? ClYes CINo ‘The pages that folow contain statements that describe how children may act. Please read each phrase and select the ‘option that best describes how often your child shows these behaviors. Please mark one option for every statement. Use these guidelines to mark your responses: ‘When presented with the opportunity, my child... responds in this manner Almost Always (20% or more ofthe time. fo ERIE responds in this manner Frequently (75% ofthe time), ETEIERINGY responds inthis manner Half the Time (50% of the time}. responds in this manner Occasionally (25% of the tne). responds in tis manner Almost Never (10% or less of the time), = Coir Does Not Apply Ifyou are unabe to answer because you have not observed the behavior or believe that it does nt apply to your child, please check Does Not Apply. Pyehcorp is an imprint of Pearson Clinical Assessment. @PsychCor yrson Executive Office 5601 Green Valley Drive Bloomington, MN 55437 PsychCorm, 800.627.9871 wore Pearsonclinicalcom Copyright © 2014 NCS Pearson, Inc. Al rights reserved. ‘Warning: No part of ths publication may be reproduced or transmitted in any form or by any ‘means, electronic or mechanical, including photocopy, recording, or any information storage and ‘otieval system, without permission in wring from the copysight owner, Pearson, the PSI logo, PsychCorp, and Sensory Profile are trademeris in the U.S. and/or other countries of Pearson Education, Ine, or is afilate(s) Printed in the United States of America. 7891011 12ABCDE Product Number 0358700058 RO cae E My child. reacts strongly fo unexpected or loud noses for example, sons, dog barking, har dye. holds hands over ears o protect them from sound. struggles to complete tasks when music or TV i on. is distracted when there fa lot of noise around | 2 3 4 5 becomes unproductive with background noise (for example, fan, retigerato). = — 7 a tunes me out or seems to ignore me. ‘ems not to hear when | call his or her name (even though hearing is OF). ‘enjoys strange noises of makes noise(s for fun. | AUDITORY Raw Score AUDITORY Processing Comments: My child... prefer o play or workin ow ihtng 40 preter bright cols or pattems for clothing. I | 11. exjoys looking a visual deta in obec | 12 needs hep to find objects that are obvious to others. | 18's more bothered by bright lights than other same-aged children. 14 watches poopie as they move around the room. Os “This tom is pat ofthe VISUAL Raw Sco. VISUAL Raw Score Is bothered by bright ligts for example, hides from sunlight through car window) ei VISUAL Processing Comments: 2 BY CHILD sensory Protte 2 ‘Nmost Aways = 00% ar more | Frequent =75% [af the Teno =60% | Occasionally= 5% | Armoat Never = 10% orloss Te My child. shows distress during grooming (for example, fights or cries during haircutting, face washing, fingernail cutting) 17 becomes inated by wearing shoes or socks. 18 shows an emotional or aggressive response to being touched 19 becomes anvious when standing close to others (for example ina tn). rubs or scratches a part of the body tht has been touched. touches people or objects to the point of annoying others.

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