Does your child

1. Avoid certain textures of food? ___ Y ___ N

2. Dislike being cuddled?   ____Y___N

3. Dislike having hair and/or face washed? ___ Y ___ N

4. Prefer certain textures of clothing? ___ Y ___ N

5. Isolate self from other children? ___Y ___N

6. Frequently bump or push others? ___ Y ___ N

7. Seem fearful in space (i.e., going up and down stairs, riding the teeter-totter, afraid of heights)? ___ Y ___ N

8. Appear clumsy, often bumping into things and/or falling down? ___ Y ___ N

9. Have difficulty sitting still or focusing, stays in "perpetual motion"? ___ Y ___ N

10. Have difficulty with transitions? ___Y___N

11. Shut down or have meltdowns? ___ Y ___ N

12. Seem to be emotionally "up and down"? ___ Y ___ N

13. Have a low frustration tolerance? ___ Y ___ N

14. Rock, bang head, hit easily when frustrated? ___ Y ___ N

15. Seem accident prone? ___ Y ___ N

16. Have difficulty dressing and/or fastening clothes? ___ Y ___ N 

17. Have difficulty with pencil activities? ___ Y ___ N

18. Have a weak grasp? ___ Y ___ N

19. Have a diagnosed muscle pathology (i.e., spasticity,flaccidity, rigidity, etc.)? ___ Y ___ N

20. Become tired easily? ___ Y ___ N

21. Seem overly sensitive to sound? ___ Y ___ N

22. Like to make loud noises? ___ Y ___ N

23. Seem confused about the direction of sounds? ___ Y ___ N

24. Have difficulty eye-tracking? ___ Y ___ N

25. Appears sensitive to light? ___ Y ___ N

26. Becomes excited when confronted with a variety of visual stimuli? ___ Y ___ N

 *Adapted from Pat Wilbarger, OTR/L, revised by Robyn Colley, OTR/L, Sensory Checklist*

 If you have answered Yes for five items or more, speak to your Pediatrician about an Occupational Therapy referral, or consult with one of our Occupational Therapists.