JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Sensory Processing Screener
Fill out this form, and our occupational therapists will review to determine if further follow-up is recommended. Thank you!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Child's First and Last Name:
*
Your answer
Person filling out form (first and last name) and relationship to child:
*
Your answer
Phone number to contact for follow up:
*
Your answer
Child's Birthdate:
Your answer
AUDITORY
(
check which items are true for your child)
Has difficulty paying attention in the classroom or in group activities
Is distressed by large gatherings such as holidays or eating in a restaurant
Reacts negatively to loud or unexpected noises
Bothered by background noises such as fans, lawnmowers, and others talking
Seems not to respond to own name when called
On a scale of 1-10, how much do these
auditory
items impact your child’s daily functioning?
not at all
1
2
3
4
5
6
7
8
9
10
very much so; unable to engage in normal/expected activities
Clear selection
Any additional comments related to
auditory
?
Your answer
OLFACTORY/GUSTATORY
(
check which items are true for your child)
Seems bothered more than most by certain smells
Seems bothered more than most by certain tastes
Picky or selective eater
Avoids entire food groups or specific textures
Frequently or easily gags or vomits
On a scale of 1-10, how much do these
olfactory/gustatory
items impact your child’s daily functioning?
not at all
1
2
3
4
5
6
7
8
9
10
very much so; unable to engage in normal/expected activities
Clear selection
Any additional comments related to
olfactory/gustatory
?
Your answer
TACTILE
(
check which items are true for your child)
Has difficulty with certain textures of clothing (i.e. refuses jeans, distressed by sock seams, etc.)
Does not like to engage in messy activities
Struggles with having their face or hair washed
Discrepancies with pain tolerance (either as higher or lower tolerance than most)
On a scale of 1-10, how much do these
tactile
items impact your child’s daily functioning?
not at all
1
2
3
4
5
6
7
8
9
10
very much so; unable to engage in normal/expected activities
Clear selection
Any additional comments related to the
tactile
system?
Your answer
VISUAL
(
check which items are true for your child)
Easily distracted by other objects in the room
Bumps into objects as if they were not there
Has trouble finding certain toys among a group of items
Squints or rubs eyes frequently
Difficulty copying writing (either on a desk or from the board)
On a scale of 1-10, how much do these
visual
items impact your child’s daily functioning?
not at all
1
2
3
4
5
6
7
8
9
10
very much so; unable to engage in normal/expected activities
Clear selection
Any additional comments related to the
visual
system?
Your answer
PROPRIOCEPTIVE
(
check which items are true for your child)
Loves running, jumping, or crashing activities
Uses excessive force for the activity (e.g., stomps feet excessively, breaks toys, rips paper, etc.)
Constantly chews on things (e.g., clothes, toys, water bottles)
Frequently hits, bites, or kicks others
Loves big bear hugs
On a scale of 1-10, how much do these
proprioceptive
items impact your child’s daily functioning?
not at all
1
2
3
4
5
6
7
8
9
10
very much so; unable to engage in normal/expected activities
Clear selection
Any additional comments related to the
proprioceptive
system?
Your answer
VESTIBULAR
(
check which items are true for your child)
Loves spinning or swinging activities
Thrill seeker, doesn’t always recognize danger in play
Easily gets motion sickness
Has difficulty with balance activities
Fearful of heights
On a scale of 1-10, how much do these
vestibular
items impact your child’s daily functioning?
not at all
1
2
3
4
5
6
7
8
9
10
very much so; unable to engage in normal/expected activities
Clear selection
Any additional comments related to the
vestibular
system?
Your answer
INTEROCEPTION
(
check which items are true for your child)
Struggles with sleep (falling asleep, staying asleep)
Is unable to report being hungry or full accurately
Struggles with control of bladder and bowels (e.g., constipation, bed wetting, etc.)
Always hot or always cold
Significant shifts in moods or emotions throughout the day without just cause (matching response to situation)
On a scale of 1-10, how much do these
interoception
items impact your child’s daily functioning?
not at all
1
2
3
4
5
6
7
8
9
10
very much so; unable to engage in normal/expected activities
Clear selection
Any additional comments related to the
interoception
system?
Your answer
Did your child meet their developmental milestones on time (e.g., sitting, crawling, walking)?
Your answer
Does your child appear clumsy or have difficulty with motor coordination?
Your answer
Does your child have difficulty with getting dressed or manipulating fasteners (e.g., buttons, zippers)?
Your answer
Is it difficult to complete daily routines (e.g., getting out the door for school, getting ready for bed, etc.)?
Your answer
Does your child have difficulty with mealtimes?
Your answer
Which provider, if any, sent you this form? This helps us know where to direct the results.
I found it on your website or a friend sent it to me -- I'm inquiring for more information
Emily Sonzogni, SLP
Kristy Lawson, OT
Kalista McMullin, SLP
Julie Ott, SLP
Holly Harward, SLP
Alicia Hales, SLP
Tammy Price, SLP
Lexi Sklarsky, OT
Kailee Williams, OT
I'm not sure
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Prickly Pear Pediatric Therapy.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
