Client's Name
*
First Name
Last Name
Exhibits Poor Balance
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Had Delayed crawling, standing and/or walking
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Poor muscle tone (Extremely flexible)
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Experiences motion sickness
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Dislike of heights, swings, merry go rounds, escalators, elevators
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Easily disoriented and/or poor sense of direction
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Clumsy
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Difficulty remaining still; may actively seek movement such as spinning and/or rocking
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Difficulties with space perception
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Walks or walked on toes
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Vestibular Function Tally
Concerned about hearing as an infant
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Inability to sing in tune
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hypersensitive to sounds
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Misinterprets questions
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Confuses similar sounding words; frequently need to have words repeated
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Inability to follow sequential instructions
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Flat and monotonous voice
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hesitant speech
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Small vocabulary
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Confusion or reversal of letters
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Auditory Function Tally
Misreads words
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Misses or repeats words or lines
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Reads slowly
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Needs to use finger or marker as a pointer
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Inability to remember what was read
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Poor concentration
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Poor focus while reading ie letters move or jump around on the page
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Crooked or sloped handwriting
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Letters poorly balance with one eye covered or while trying to read sideways
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Sensitivity to light
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Visual Dysfunction Tally
Poor posture
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Constant fidgeting or moving
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Excessive desire to be held
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Provokes fights
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hooks feet around legs of desk for support
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Problem identifying body parts in space
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Bumps into things often
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Poor Balance
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Rocks body or bangs head
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Does not like heights
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Proprioceptive Function Tally
Undersensitive to most things
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Doesn't notice or respond when cut
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
High threshold for pain
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Doesn't sense the feeling of hot or cold
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Craves contact sports
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Doesn't notice when sits down on an object
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Provokes roughhousing or fighting
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Not ticklish
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Compulsively touches
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Acts like a bull in a china shop
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hypotactile Tally
Seems hypersensitive all the time
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Dislikes playing sports
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Dislikes being touched
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hates tags on clothes
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Allergic skin reactions
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hates makeup and/or jewellery
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Poor body temperature control
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Does not like clothing on arms or legs
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Low external pain threshold
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Doesn't like touching
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hypertactile Tally
Exhibits increased sensitivity to taste and smell
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Gags at the smell of certain foods
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Avoids going to bathroom at the risk of wetting pants the smell is repugnant
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Likes bland foods
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Avoids children with dirty or smelly clothes
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Complains about others bad breath
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Misbehaves after house is cleaned with solvents
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Sensitive to smoke
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Avoids foods and places with strong cooking smells
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Sniffs everything
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hypersensitivity Smell and Taste Tally
Never comments about strong smells
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Never notices baking smells such as cookies
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Overfills mouth
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Avoids foods because of the way it looks
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Never sniffs
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hates to eat, even sweets
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Chews on things like pens
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Does not notice strong smells like something burning
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Eats indiscriminately; will reach for anything, even at some risk, like poison
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Extremely picky eater
0 - Doesn't apply at all
1
2
3
4
5 - Applies half of the time
6
7
8
9
10 - Almost always
Hyposensitivity Smell and Taste Tally
