Which hand does your child use for writing?
Which hand does your child use for eating?
Please check all that apply. My child:
Objects to being touched or cuddled
Was irritable in infancy, particularly when held
Prefers to touch rather than to be touched
Prefers certain textures of clothign
Dislikes having hair and face washed
Avoids certain textures of food
Seems fearful in space (going up and down stairs, swings, etc)
Prefers fast-moving or spinning rides
Becomes easily motion sick
Appears to be in perpetual motion. Difficulty sitting still
Appears clumsy- often bumps into things or falls down
Has difficulty with transitions
Seems to be emotionally up and down
Rocks, hits, OR bangs head when frustrated
Shuts down or has frequent meltdowns
Has difficulty with pencil tasks
Has difficulty manipulating small objects
Has difficulty dressing and/or fastening clothing or tying shoes
Seems overly sensitive to sound
Seems confused about the direction of sounds
Likes to make loud noises
Has difficulty eye-tracking
Appears sensitive to light
Becomes excited when confronted with visual stimulation
Has a diagnosed muscle pathology (spasticity, rigidity, flaccidity)
Seems weaker than others his/her age
Seems stronger than others his/her age
Does your child currently receive:
Mental Health Counseling
Does your child have difficulty relating to or playing with other children?
My child prefers playing with:
Same age children
What activities (sports, hobbies, movies, etc.) does your child enjoy?
Any additional comments related to developmental history:
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This form was created inside of Pace Brantley School.