Sensory Integration Checklist

Child’s Name:__________________________Completed by:____________________________

Birthdate:___________________

Check the items where the child has difficulty. Refer to Occupational Therapist to determine need for further assessment.

_____ Fear of new tasks and situations ______Overly aggressive/explosive
_____Overly passive ______Easily frustrated
_____Impulsive ______Emotionally labile
_____Can’t follow directions ______Unorganized
_____Can’t get work done on time ______Can’t work independently
_____Distractable/short attention span ______Can’t wait/take turns
_____Doesn’t learn new activities easily ______Clumsy
_____Tires easily ______Difficulty hopping, jumping, skipping
_____Slouches, poor posture ______Always something moving(leg, hand, body)
_____Poor pencil grasp ______Poor handwriting
_____Breaks pencil or crayon ______Awkward with pencil/scissors
_____Can’t copy from board/book ______No consistent hand preference
_____Letter or number reversals ______Likes physical contact
_____Avoids being touched ______Dislikes getting hands dirty
_____Oral overflow (tongue out, drooling, hands in mouth) ______Can’t keep hands to self
_____Fearful of activities moving through space ______Poor balance
_____Excessive need for swinging, spinning, rocking ______Delayed speech and language
_____Difficulty screening out visual/auditory stimuli ______Difficulty with dressing skills
_____Difficulty discriminating shapes, colors, letters ______Makes repetitious vocal sounds
_____Responds negativity to loud or unexpected noise ______Positions hands awkwardly
_____Walks on toes ______Rejects textures of food, clothing
_____Smells objects ______Self-stimulation/self-injury
_____Grinds, clinches teeth

Comments:

 

 

 

 

 

Parent-Child Services Group, Inc. 4/99
Kathy Boling, OTR/L
Permission to copy for educational purposes only