Adult Assessment Form 1 of 4

Client's Name *

First Name

Last Name

Carer's Name

If applicable

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Fear Paralysis Reflex *

Anxiety seemingly unrelated to reality.

Hypersensitivity to touch, sound, changes in visual field.

Dislike of change or surprise, poor adaptability.

Breath holding.

Fear of social embarrassment.

Insecure/ lack of trust in oneself.

Overly clingy or may be unable to accept or demonstrate affection easily.

Negativism, defeatist attitude, won't try new activities, especially where comparison or excellence is expected.

Temper tantrums.

Immediate motor paralysis under stress - can't think and move at the same time.

Moro / Startle Reflex *

Excessive blinking

Hypersensitivity to sudden noise, light or movement

A hyper startle response, followed by rapid heartbeat

Difficulty with new or stimulating experiences

Impulsive behaviour

Vestibular problems (Imbalance, dizziness, motion sickness, vertigo)

Anxiety, flushing uncontrollably when embarrassed or nervous

Frequent ear and throat infections

Depleted energy, fatigue, mood swings

Dislike of change

Sensitivity to foods or food additives, chronic digestive problems from childhood

Tonic Labyrinthine Reflex *

Poor Posture

Toe walker as a kid or as an adult

Poor balance and coordination

Poor eye movement control

Visual perceptual difficulties

Afraid of heights

Difficulty judging space, distance, depth and speed

Poor concentration

Fatigue when reading or working/ studying at a desk

Spinal Galant Reflex *

Can't sit still, fidgety

Short term memory problems

Bedwetting beyond age 5, Chronic bladder control issues

Sensitive to tight clothing around waist or tags on clothes

Constant noise making

Attention and concentration problems

Difficulty coordinating normal walking gait

May affect fluency and mobility in physical activities or sports

Can contribute to the development of scoliosis (curvature) of the spine

Body tends to tilt to one side, can cause chronic back or neck pain

Asymmetrical Tonic Neck Reflex (ATNR) *

Poor handwriting

Difficulty reading and tracking

Left-Right confusion (mixed laterality), ambidextrous

Difficulty copying

ADHD/OCD characteristics

Missing parts of a line when reading

Difficulty catching a ball

Poor at sports, dancing or bilateral integration

In adults there can be chronic shoulder and/or neck problems

Poor hand/eye coordination

Judgement of distance may be affected

Symmetrical Tonic Neck Reflex (STNR) *

Poor posture (when head bends, arms will bend causing a tendency to slump when sitting - often will end up almost lying on desk to write)

Tends to hook feet under desk for support

Clumsy

Eyes fatigue when reading or focusing near on screen

As a child you skipped, missed or shortened crawling or crawled in an unusual way

Poor upper and lower body integration, affecting gross motor skills

Poor hand/eye coordination

Messy eater

Poor organisation and planning skills

Rooting and Suck Reflex *

Speech and articulation problems stuttering

Difficulty swallowing and chewing

Difficulty speaking and doing manual tasks at the same time

Involuntary tongue or mouth movements when writing or drawing

Poor manual dexterity, especially when chewing or speaking

Hypersensitivity around lips and mouth

Oral fixation - always need to be doing something with mouth (smoking, chewing gum, biting lip etc)

Dribbling and drooling

Poor manual dexterity when speaking

Hormonal imbalances or deficiencies

Palmar Grasp Reflex *

Poor fine motor skills and manual dexterity

Inappropriate pencil grip and poor handwriting

Weak immune system

Difficulty processing ideas onto paper

Poor posture and/or back pain when working at desk/computer

Constant need to always touch and hold things in hand

Difficulty or slow reading

Poor memory for details

Not good with maths or numbers

Mixed dominance, ambidextrous or left handed

Babinski Reflex *

Difficulty or delay in learning to walk (beyond 14 months)

Running awkwardly

Poor balance

Can't press toes into the ground

Problems with sports requiring balance and coordination when running

Low back pain while walking and/or standing

Shin soreness

Recurrent ankle twisting

Difficulty walking in the dark (vision is not able to assist balance)

Calf or Achilles tendonitis, injury or pain