Attention Deficit Disorder

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Sensory Learning Child Assessment Form
* Your Name:
* Address:
* City:
* State/Province:
* Zip:
* Best Telephone Number:
* Email Address:
* Child's Name:
* Date of Birth:
* Sex:
* 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 history of your child: including pregnancy, birth, any birth defects, serious illnesses, surgeries, diagnoses, and any current medications.

1. Physical Aspects

History of seizures?
History of ear infections?
Repetitive rounds of antibiotics?
Child appears not to feel pain?
Irregular sleep patterns?
Issues with bed-wetting?
Difficulty with toilet-training?
Tactile defensiveness (clothing tags, food textures)?
Appears clumsy or uncoordinated?
Can child pedal or ride a 2-wheeler?
Difficulty with fine motor skills (eating with utensils, using crayons)?
Any regression after immunizations?
Any detoxifying or chelating procedures?
Are there any digestion/elimination problems?
Is dietary modification in place?

2. Visual/Motor Skills

Poor eye contact?
Sideways gazing?
Tracking Problems?
Difficulty catching a ball?
Does artwork look too primitive for child's age?
Any vision correction?

3. Auditory/Language

Was there a speech delay?
Is speech now age-appropriate?
Are there 'central auditory processing' issues?
Sensitivity to sounds (blender, hair dryer, vacuum)?
Does child have a sense of rhythm?

4. Behavioral Responses to Sensory Stimuli

Overwhelmed in sensory-rich environments?
Under responsive to sensory stimuli?
Any 'self-stimming' behaviors present?
Mesmerized by lights or fans?
Addictive tendencies to TV/Computer games?
Obsesses with routines and/or repetitive patterns?
Difficulty with transitions?

5. Emotional Responses to Sensory Stimuli

Difficulty showing affection?
Shows lack of empathy?
Has unreasonable fears?
Has frequent meltdowns/tantrums?
Angry and/or aggressive behavior?
High Anxiety?
Often Depressed?
Night Terrors?
Has extreme shyness?
Controls environment and manipulates people?
Difficult relationships with peers?
Missing social cues?
Child feels he has no friends?
Frequently teased by peers?

6. Academic, Visual/Auditory Skills

Difficulty making progress with handwriting?
Difficulty concentrating and attending to task?
Difficulty understanding symbols (shapes, numbers, letters, etc.)?
Difficulty following multi-step oral directions?
Difficulty learning to read?
Poor comprehension when reading?
Can child decode phonetically (sound out words)?
Can child learn spelling words easily?