Infants and Toddlers |
| ____ | My infant/toddler has problems eating. |
| ____ | My infant/toddler refused to go to anyone but me. |
| ____ | My infant/toddler has trouble falling asleep or staying asleep |
| ____ | My infant/toddler is extremely irritable when I dress him/her; seems to be uncomfortable in clothes. |
| ____ | My infant/toddler rarely plays with toys, especially those requiring dexterity. |
| ____ | My infant/toddler has difficulty shifting focus from one object/activity to another. |
| ____ | My infant/toddler does not notice pain or is slow to respond when hurt. |
| ____ | My infant/toddler resists cuddling, arches back away from the person holding him. |
| ____ | My infant/toddler cannot calm self by sucking on a pacifier, looking at toys, or listening to my voice. |
| ____ | My infant/toddler has a "floppy" body, bumps into things and has poor balance. |
| ____ | My infant/toddler does little or no babbling, vocalizing. |
| ____ | My infant/toddler is easily startled. |
| ____ | My infant/toddler is extremely active and is constantly moving body/limbs or runs endlessly. |
| ____ | My infant/toddler seems to be delayed in crawling, standing, walking or running. |
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Pre-schoolers |
| ____ | My child has difficulty being toilet trained. |
| ____ | My child is overly sensitive to stimulation, overreacts to or does not like touch, noise, smells, etc. |
| ____ | My child is unaware of being touched/bumped unless done with extreme force/intensity. |
| ____ | My child has difficulty learning and/or avoids performing fine motor tasks such as using crayons and fasteners on clothing. |
| ____ | My child seems unsure how to move his/her body in space, is clumsy and awkward. |
| ____ | My child has difficulty learning new motor tasks. |
| ____ | My child is in constant motion. |
| ____ | My child gets in everyone else's space and/or touches everything around him. |
| ____ | My child has difficulty making friends (overly aggressive or passive/ withdrawn). |
| ____ | My child is intense, demanding or hard to calm and has difficulty with transitions. |
| ____ | My child has sudden mood changes and temper tantrums that are unexpected. |
| ____ | My child seems weak, slumps when sitting/standing; prefers sedentary activities. |
| ____ | It is hard to understand my child's speech. |
| ____ | My child does not seem to understand verbal instructions. |
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Grade schoolers |
| ____ | My child is overly sensitive to stimulation, overreacts to or does not like touch, noise, smells, etc. |
| ____ | My child is easily distracted in the classroom, often out of his/her seat, fidgety. |
| ____ | My child is easily overwhelmed at the playground, during recess and in class. |
| ____ | My child is slow to perform tasks. |
| ____ | My child has difficulty performing or avoids fine motor tasks such as handwriting. |
| ____ | My child appears clumsy and stumbles often, slouches in chair. |
| ____ | My child craves rough housing, tackling/wrestling games. |
| ____ | My child is slow to learn new activities. |
| ____ | My child is in constant motion. |
| ____ | My child has difficulty learning new motor tasks and prefers sedentary activities. |
| ____ | My child has difficulty making friends (overly aggressive or passive/ withdrawn). |
| ____ | My child ïgets stuck' on tasks and has difficulty changing to another task. |
| ____ | My child confuses similar sounding words, misinterprets questions or requests. |
| ____ | My child has difficulty reading, especially aloud. |
| ____ | My child stumbles over words; speech lacks fluency, and rhythm is hesitant. |
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Adolescents and adults |
| ____ | I am over-sensitive to environmental stimulation: I do not like being touched. |
| ____ | I avoid visually stimulating environments and/or I am sensitive to sounds. |
| ____ | I often feel lethargic and slow in starting my day. |
| ____ | I often begin new tasks simultaneously and leave many of them uncompleted. |
| ____ | I use an inappropriate amount of force when handling objects. |
| ____ | I often bump into things or develop bruises that I cannot recall. |
| ____ | I have difficulty learning new motor tasks, or sequencing steps of a task. |
| ____ | I need physical activities to help me maintain my focus throughout the day. |
| ____ | I have difficulty staying focused at work and in meetings. |
| ____ | I misinterpret questions and requests, requiring more clarification than usual. |
| ____ | I have difficulty reading, especially aloud. |
| ____ | My speech lacks fluency, I stumble over words. |
| ____ | I must read material several times to absorb the content. |
| ____ | I have trouble forming thoughts and ideas in oral presentations. |
