Historia sensoriomotora Complete el formulario de historial sensoriomotor SENSORIMOTOR HISTORY Parent Name* First Last Parent Email* Child’s First Name:Child’s Last Name:Date: MM slash DD slash YYYY BASIC SENSORY FUNCTIONINGPlease check yes or no for each item. Mark N/A for any items not appropriate for your child. If any characteristic was true at a younger age but is no lon ger, please indicate by checking the appropriate box.Seems fearful of movement or heights i.e. going up/ down stairs, climbing, or playing on swings Yes No When Younger Craves or seeks out spinning; does not get dizzy Yes No When Younger Enjoys fast rides Yes No When Younger Gets car sick easily Yes No When Younger Becomes dizzy easily Yes No When Younger Dislikes having face washed and/or teeth brushed Yes No When Younger Dislikes being touched unexpectedly Yes No When Younger Avoids getting hands in paste, fingerpaint or other ‘messy’ material Yes No When Younger Dislikes having hair washed, brushed, and/or cut Yes No When Younger Bother by tags or dislikes certain material in clothing Yes No When Younger Refuses to wear certain types of clothing Yes No When Younger Does not dress appropriately to the weather Yes No When Younger Tends to b ump or push others, esp. when standing in line or seated in circle Yes No When Younger Tends to feel or react to pain more than others Yes No When Younger Less aware/responsive to pain than others Yes No When Younger Comments:VISUALBumps into furniture, walls, etc. often Yes No When Younger Poor eye contact Yes No When Younger Dislikes bright lights or sunshine Yes No When Younger Difficulty putting together puzzles Yes No When Younger Poor understanding of spatial or directional Concepts (before, behind, right, left) Yes No When Younger Poor spacing of work on paper Yes No When Younger Reverses or omits numbers, letters, or words Yes No When Younger Gets lost easily, even in familiar surroundings Yes No When Younger Comments:AUDITORYResponds negatively to loud or unexpected noises Yes No When Younger Has difficulty functioning or paying attention if there is a lot of noise around Yes No When Younger Does not appear to hear all sounds Yes No When Younger Speech is difficult to understand Yes No When Younger Has difficulty following directions Yes No When Younger Difficulty comprehending what’s going on Yes No When Younger Comments:GUSTATORY - OLFACTORY - ELIMINATIONRefuses to eat many foods, limited diet Yes No When Younger Explores by smelling Yes No When Younger Reacts negatively to smell Yes No When Younger Trouble learning urinary control Yes No When Younger Trouble learning bowel control Yes No When Younger Trouble learning bowel control Yes No When Younger Comments:MOTOR SKILLSUnusual walking pattern (drags feet, walks on toes, stiff, falls often) Yes No When Younger Appears awkward or clumsy Yes No When Younger Avoids certain motor tasks Yes No When Younger Difficulty dressing self Yes No When Younger Difficulty handling clothing fasteners Yes No When Younger Difficulty with toileting skills Yes No When Younger Difficulty with cutting, drawing, writing Yes No When Younger Inconsistent hand dominance Yes No When Younger Comments:Poor energy/endurance Yes No When Younger SOCIAL - EMOTIONALEasily distracted Yes No When Younger Impulsive Yes No When Younger Lacks confidence (says ‘I can ’t or ‘too hard’) Yes No When Younger Easily frustrated Yes No When Younger Dislikes changes in routine Yes No When Younger Disorganized. messy Yes No When Younger Slow completing routine tasks or school work Yes No When Younger Wiggles a lot, can’t sit still Yes No When Younger Happiest playing alone Yes No When Younger Finds it hard to make friends among peers Yes No When Younger Prefers to play with younger (or older) children Yes No When Younger Poor response to behavioral interventions Yes No When Younger Has temper tantrums Yes No When Younger Seems anxious Yes No When Younger Tends to be controlling Yes No When Younger Comments:CAPTCHA
