AASH Self Report Questionnaire
Adult and Adolescent Sensory History Self-Report Questionnaire
Jane Koomar, PhD, OTR/L, FAOTA & Teresa May-Benson, ScD, OTR/L, FAOTA (Contributions by Mandy Hurwitz, Rebecca Kahler Reis, Stacey Szkiut

There are 10 sections to this Questionnaire with between 10 and 30 questions in each section. Ensure you have at least 15-20 minutes to complete the full questionnaire.
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Email *
What is your name and nickname? *
What's the date today? *
MM
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DD
/
YYYY
What's your birth date? *
MM
/
DD
/
YYYY
What's your address and phone number? *
What's your gender? *
What is your race/ethnicity? *
What's your marital status? *
What is the highest education you've completed? *
What's your occupation? *
What's the reason for your referral? *
What do you hope to gain from this evaluation and / or treatment? *
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