Sensory Learning: Adult Assessment Form

Click below if you are a Medical or Allied Healthcare professional interested in incorporating the Sensory Learning Program into your practice.

Professional Form

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Sensory Learning Adult Assessment Form

* Your Name:
* Address:

* City:
* State/Province:
Country:
* Zip:
* Best Telephone Number:
* Email Address:
* Date of Birth:
* Gender:
* Age:
* denotes required fields. All information will be held in strict confidence.

Please select the Sensory Learning Center you would like to work with.

First, tell us how you heard about the Sensory Learning Program.

Now, please give a brief medical history: including any serious illnesses, medical diagnoses, and any current medications.

1. Physical Aspects

History of heart conditions?
History of seizures?
Repetitive rounds of antibiotics?
Irregular sleep patterns?
Any silver amalgam fillings?
Tactile defensiveness (clothing tags, food textures)?
Any detoxifying or chelating procedures?
Are there any digestion/elimination problems?

Describe your diet.

2. Visual Issues

Any vision correction?
Tracking problems?
Strabismus?
Double vision?
Light sensitivity?

3. Auditory/Language

Hearing aid?
Are there speech production issues?
Are there 'central auditory processing' issues?
Sensitivity to sounds (blender, hair dryer, vacuum)?

4. Balance Issues

Please describe any balance or dizziness issues.

5. Behavioral Responses to Sensory Stimulation

Any sensation seeking behaviors?
Any sensory sensitivity?
Any sensation avoiding behaviors?

6. Emotional Responses to Sensory Stimuli

Please describe any emotional issues (i.e. Depression).

7. Cognitive

Please describe any cognitive issues with memory, concentration, & response time.

8. Wellness

Please describe any athletic or peek performance goals.

9. Goals

Please describe any goals you are hoping for with the Sensory Learning Program.