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Sensory Learning Assessment Form
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Email
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Date:
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Your Name
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Address
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City, State
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Zip Code
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Best Phone Number
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Patient's Name
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Date of Birth
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Sex
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Age
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First, tell us how you heard about the Sensory Learning Program?
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Now, please give a brief history of the patient: including pregnancy, birth, any birth defects, serious illnesses, surgeries, diagnoses, and any current medications.
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Please select the following boxes that correspond with the patient (Older patient as when they were a child):
Physical Aspects
History of seizures?
History of ear infections?
Repetitive rounds of antibiotics?
Patient appears not to feel pain?
Irregular sleep patterns?
Issues with bed-wetting?
Difficulty with toilet-training?
Tactile defensiveness (clothing tags, food textures)?
Appears clumsy or uncoordinated?
Can patient pedal or ride a 2-wheeler?
Difficulty with fine motor skills (eating with utensils, using crayons)?
Any regression after immunizations?
Any detoxifying or chelating procedures?
Are there any digestion/elimination problems?
Is dietary modification in place?
Visual/Motor Skills
Poor eye contact?
Sideways gazing?
Tracking problems?
Strabismus?
Difficulty catching a ball?
Does artwork look too primitives for child's age?
Any vision correction?
Auditory/Language
Was there a speech delay?
Is speech now age-appropriate?
Are there 'central auditory processing' issues?
Sensitivities to sounds (blender, hair dryer, vacuum)?
Does patient not have a sense in rhythm?
Behavioral Responses to Sensory Stimuli
Overwhelmed in sensory-rich environments?
Hyperactive?
Under responsive to sensory stimuli?
Any 'self-stimming' behaviors present?
Mesmerized by lights or fans?
Hand-flapping?
Toe-walking?
Addictive tendencies to TV/Computer games?
Obsesses with routines and/or repetitive patterns?
Difficulty with transitions?
Emotional Responses to Sensory Stimuli
Difficulty showing affection?
Shows lack of empathy?
Has unreasonable fears?
Has frequent meltdowns/tantrums?
Angry and or aggressive behavior?
High anxiety?
Often Depressed?
Night Terrors?
Has extreme shyness?
Controls environment and manipulates people?
Difficult relationships with peers?
Missing social cues?
Patient feels he has no friends?
Frequently teased by peers?
Academic, Visual/Auditory Skills
Difficulty making progress with handwriting?
Difficulty concentrating and attending to task?
Difficulty understanding symbols (shapes, numbers, letters, etc)?
Difficulty following multi-step oral directions?
Difficulty learning to read?
Poor comprehension when reading?
Can patient decode phonetically (sound out words)?
Can patient learn spelling words easily?
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