Iowa Family Chiropractic Pediatric Sensory Questionnaire
Please fill out the following questionnaire prior to your child’s appointment. Check the box if the statement is true for your child. Leave it blank if it is false, or if the statement does not apply.
My child has unusual eating habits (strong preferences, eats at odd times, etc.).
My child has unusual sleeping habits or sleep schedule.
My child has difficulty with transitions, whether they are major life changes or small everyday changes (moving from one activity to another, inside to outdoors, etc.).
My child becomes engrossed in one single activity for a long time and seems to tune out everything else.
My child spends hours at a time on fantasy or video games and activities.
My child has a very high or very low energy level.
My child is resistant to changes in daily life and surrounding environment.
My child is bothered by clothes (certain materials, tags, seams, tights, ties, belts) and has a strong preference for certain types of clothing.
My child is bothered by light touch, i.e. someone gently touching to rubbing their hand, face, leg or back.
My child is excessively ticklish.
My child is distressed by others touching; would rather be the “toucher” than the “touchee”; often does not like being hugged.
My child is very sensitive to pain.
My child dislikes the feeling of showers or being splashed.
My child has difficulty going to the beach, as sand is irritating to the touch.
My child avoids touching anything “messy”.
My child washes their hands frequently, and/or only touches things with fingertips or through fabric.
My child cannot wear new or “stiff” clothing that have not been washed; prefers fabric softener.
My child hates being barefoot, or hates wearing shoes/socks.
My child frequently gets car sick or motion sick.
My child has difficulty riding on elevators, escalators, or moving sidewalks.
My child avoids amusement park rides that drop, climb, spin or go upside down.
My child has difficulty eating foods with mixed textures, or one particular texture.
My child prefers bland foods, dislikes anything spicy.
My child becomes nauseated or gags from certain cooking, cleaning, perfume, public restroom, or bodily odors.
My child becomes overstimulated or over-aroused when people come to the hours or when in crowded places.
My child becomes overly excited/aroused in group settings.
My child avoids crowds and hides, disappears, or acts out when guests come over.
My child is sensitive to noises that other people are not bothered by (clocks, appliance, fans, people talking, blenders, vacuum cleaners, animals, construction, etc.).
My child is easily distracted by auditory or visual stimuli.
My child cannot attend certain public events or places due to excessive noise.
My child overreacts to loud noises like sirens.
My child cannot sleep if the room is not completely dark.
My child has a fear of heights.
My child is bothered by their hands or face being dirty.
My child may fail to recognize stimuli that most would find alerting or strong.
My child is unable to identify foods that have gone bad by smell.
My child has difficulty being able to smell dangerous odors (smoke, noxious/hazardous solvents, something burning in the oven).
My child doesn’t seem to notice pain; gets shots/cuts/bruises and hardly feels anything.
My child is lethargic, hard to get going, appears “lazy” and unmotivated.
My child doesn’t seem to notice if hands and face are dirty.
My child is/was a late potty trainer (didn’t feel the need to go) or has/had chronic bedwetting issues.
My child doesn’t seem to get dizzy.
My child might not catch self when falling or protect self from getting hurt; lacks reflexes.
My child doesn’t interact with peers or adults; is hard to engage, an observer and not an active participant.
My child is the last to notice when a person enters the room.
My child has difficulty waking up in the morning, and often doesn’t notice an alarm clock.
My child loves to touch and be touched, has to touch everything.
My child has to fidget and “fiddle” with things all the time.
My child often touches and twists their own hair or others’ hair.
My child is a thrill seeker; loves fast and/or dangerous rides and sports.
My child seeks out fast, spinning and/or upside down rides.
My child will often rock or sway their body back and forth while seated or standing.
My child frequently tips their chair on the back two legs.
My child is restless when sitting through a lecture, presentation or movie.
My child constantly chews on things, sucks thumb, and/or grits teeth.
My child prefers foods with very strong tastes and flavors.
My child bites on their nails and fingers.
My child bites their lips or insides of their cheeks.
My child frequently shakes one leg.
My child loves to sleep under multiple blankets.
My child seeks out crashing and “squishing” activities; may jump on furniture or run into other people.
My child cracks their knuckles.
My child loves crunchy foods (popcorn, carrots, chips, nuts, pretzels, etc.).
My child identifies objects by smell, has to smell everything, or uses smell to determine whether they like something or someone.
My child has difficulty settling down for sleep.
My child can’t identify objects by touch alone.
My child has difficulty finding things in a desk, bag, or pocket without looking.
My child has difficulty heating food to the correct temperature, feeling if it is too hot or too cold.
My child has difficulty locating items in a cupboard, drawer, closet or on a grocery shelf.
My child has difficulty recognizing/interpreting/following traffic signs.
My child gets disoriented and/or lost easily in stores, buildings, etc.
My child has difficulty concentrating on or watching a movie/TV show when there is background noise or other distractions.
My child has difficulty remembering or understanding what people are saying.
My child has difficulty following directions if given tow or three at a time.
My child cannot complete concentrated tasks if noise is present.
My child talks too loud or too softly.
My child has difficulty licking an ice cream cone neatly.
My child has difficulty with speech and annunciation.
My child bumps into things frequently.
My child often pushes too hard on objects, accidentally breaking them.
My child has difficulty judging how much pressure to apply when doing tasks or picking something up.
My child often reverses numbers and letters or processes them backward.
My child has difficulty telling time on an analogue clock.
My child has difficulty reading and understanding a map, bus schedule, or directions.
My child has difficulty reading text on a computer screen.
My child has difficulty distinguishing different tastes and/or flavors of food or drink.
My child has difficulty lining up numbers correctly for math problems and/or balancing a checkbook.
Sensory-Based Motor Abilities
My child has difficulty learning to ride a bike or other moving toys/games.
My child is clumsy, uncoordinated and/or accident prone.
My child has difficulty walking on uneven surfaces.
My child has difficulty with fine motor tasks such as buttoning, zipping, tying, etc.
My child confuses right and left sides.
My child prefers sedentary tasks, avoiding sports or physical activities.
My child has difficulty with handwriting (writes slowly, messy, hand hurts).
My child frequently bumps into people and things.
My child is easily fatigued with physical tasks.
My child frequently misses when putting objects on the table.
My child is a messy eater (struggles with utensils, spills and drops food).
My child often knocks drinks or other things over when reaching for them.
My child has difficulty pouring drinks.
My child frequently drops items.
My child often hums or talks to self while concentrating on a task.
My child has difficulty with motor tasks requiring several steps.
My child has difficulty learning new motor tasks (a dance, sport or exercise activity, how to drive, etc.).
My child loses balance frequently, maybe even while standing still.
My child has significant difficulty learning to type without looking at the keyboard.
Social and Emotional
My child dislikes changes in plans or routines, needing structure.
My child is often described as “stubborn”, “defiant”, or “uncooperative”.
My child is very emotional and sensitive, may also be prone to crying.
My child can’t seem to finish anything.
My child has difficulty making decisions.
My child is seen as rigid, bossy and controlling.
My child prefers solitary activities over group participation.
My child is often impatient and/or impulsive.
My child doesn’t always understand social cues and nonverbal (body) language.
My child has difficulty with authority figures.
My child has trouble relating to and socializing with peers and colleagues.
My child has difficulty accepting defeat or forgiving themselves.
My child frequently gets angry or has moments of rage.
My child is easily frustrated.
My child needs sameness and routines; needs to know what to expect.
My child often has panic or anxiety attacks.
My child has many fears and phobias.
My child has OCD-type qualities (can’t let foods touch on a plate, has to wear clothes a certain way, other obsessions or compulsions).
My child is easily distractible and often unorganized.
My child hates surprises.
My child has difficulty seeking out and maintaining relationships.
My child avoids eye contact.
My child has difficulty falling asleep or getting on a sleep schedule.
My child has heart rate issues (heart beats fast for no reason, doesn’t slow when at rest, or doesn’t speed up for tasks that require a higher heart rate).
My child has a respiration rate that is too fast or slow.
My child is over- or under-sensitive to bowel and bladder sensations.
My child is over- or under-sensitive to sensations of hunger or thirst.
My child has irregular, inconsistent bowel, bladder and appetite sensations.
My child has difficulty with temperature regulation (always hot or cold).
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