Sensory Learning Assessment Form Name First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneChild's name Date of Birth MM slash DD slash YYYY Sex Male Female Please provide details about your child including pregnancy, birth, any birth defects, serious illnesses, surgeries, diagnoses and any current medicationsPhysical Aspects History of seizures History o 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 (utensils, coloring)? Any regression after immunizations? Any detoxifying or chelating problems? Are there any digestion/elimination problems? Is dietary modification in place? Visual/Motor Skills - Check all that apply Poor eye contact? Sideways gazing? Tracking problems? Strabismus? Difficulty catching a ball? Does artwork look too primitive for child's age? Any vision correction? Auditory/Language Was there a speech delay? Is speech now age- appropriate? Are there 'central auditory processing' issues? Sensitivity to sounds (blender, hair dryer)? Does child have a sense of rhythm? Behavioral Responses to Sensory Stimuli - check all that apply Overwhelmed in sensory-rich environments? Hyperactive? Under responsive to sensory stimuli? Any 'self-skimming' behaviors present? Mesmerized by lights or fans? Hand-flapping? Toe-walking? Addictive tendencies to TV/Computer games? Obsesses with routines and/or repetitive patterns? Difficultly with transitions? Emotional Responses to Sensory Stimuli - Check All That Apply 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 Academic, Visual/Auditory Skills - Check All That Apply Difficulty making progress with handwriting? Difficulty concentrating and attending to task? Difficulty understanding symbols (shapes, nmbers etc)? Difficulty following mult-step oral directions? Difficulty learning to read? Poor comprehension with reading? Can child decode phonetically (sound out words)? Can child learn spelling words easily?