Caregiver Questionnaire
7E 3:0 to 14z11years
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CI]ILD
Ilnropv Dporrc,Z
ST
c- Test Date
FOR OFFICE USE ONLY
Calculation of Child's Age
Year Month
I
() Birth Date
Winnie Dunn, PhD, OTR, FAOTA
Age
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Child's First Name: Child's Middle Name:
Child's Last Name: lD Number:
Child's Preferred Name (if different from above):
Gender: !Male trFemale Birth Date: _l_l_ Test Date: _l_
Examiner/Service Provider's Name:
Examiner/Service Provider's Profession:
Completed by/Caregiver's Name:
Caregiver's Relationship to Child:
Name of School/Daycare Center:
School Grade/Level:
ln what order was your child born in relation to siblings (for example, 1st child, 3rd child, etc.)?
trOnly Child nlst tr2nd tr3rd tr4th nsth n Other
Have there been more than three children between the ages of birth through 18 years living in your household during
the past 12 months? trYes trNo
INSTBUCTIONS
The pages that follow contain statements that describe how children may act. Please read each phrase and select the
option that best describes how often your child shows these behaviors. Please mark one option for every statement.
Use these guidelines to mark your responses:
my child.
n this manner Almost Always (90% or more of the time).
n this manner Frequently (75% ot the time).
n this manner Half the Time (50% of the time).
n this manner Occasionally (25% of the time).
Almost NeverI l in this manner Almost Never (10% or less of the time).
unable to answer because you have not observed the behavior or believe
that it does not apply to your child, please check Does Not Apply
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123456789101112A8CDE Product Number 01 58700058
Almost Always = 90% or more Frequently = 750lo Half the Time = 50% Occasionally = 25olo Almost Never = 1 0% or less
eot
E
4 3 0
reacts strongly to unexpected or loud noises (for example, sirens, dog barking,
1
hair dryer)"
2 holds hands over ears to protect them from sound.
SN 3 struggles to complete tasks when music or TV is on
SN 4 is distracted when there is a lot of noise around
AV 5 becomes unproductive with background noise (for example, fan, refrigerator).
6 tunes me out or seems to ignore me. I
SN 7 seems not to hear when I call his or her name (even though hearing is OK). I
BG 8 enjoys strange noises or makes noise(s) for fun.
AUDITORY Flaw Score
I
AUDITOBY Processing Comments:
^!-s"
g
(U ae-
o
SN 9
10
My child...
prefers to play or work in low lighting.
prefers bright colors or patterns for clothing.
5 /1
r 0
11 enjoys looking at visual details in objects.
12 needs help to find objects that are obvious to others.
SN 13 is more bothered by bright lights than other same-aged children.
SK 14 watches people as they move around the room.
VISUAL Raw Score
is bothered by bright lights (for example, hides from sunlight through car window)..
. This item is not part of the VISUAL Raw Score.
VISUAL Processing Comments:
2 ffl cHrln Sensory Profile 2
/
Almost Always = 900/0 or more Frequently = 75% Half the Time = 50% Occasionally = 25% Almost Never = 100/o or less
TOUCH Processing
(s"
g
(! E
g o
= My child... 5 4 3
shows distress during grooming (for example, fights or cries during haircutting, face
SN 16
washing, fingernail cutting).
17 becomes irritated by wearing shoes or socks.
AV 18 shows an emotional or aggressive response to being touched
SN 19 becomes anxious when standing close to others (for example, in a line)
SN 20 rubs or scratches a parl of the body that has been touched.
JI 21 touches people or objects to the point of annoying others.
t_
displays need to touch toys, surfaces, or textures (for example, wants to get the I
SK 22
feeling of everything).
F
I I
--+-
23 seems unaware of pain
RG
RG 24 seems unaware of temperature changes.
-t- I
f-
1
I
I
,
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SK 25 touches people and objects more than same-aged children I I
-+i-{.}"_-
RG 26 seems oblivious to messy hands or face.
TOUCH Raw Score
TOUCH Processing Comments:
MOVEMENT Processing
g
"s" "s
E(5 as
E
o
a = My child... 5 4 2 1 0
pursues movement to the point it interferes wlth daily routines (for example, can't sit
SK 27
still, fidgets).
SK 28 rocks in chair, on floor, or while standing.
hesitates going up or down curbs or steps (for example, is cautious, stops before
29
moving).
SK 30 becomes excited during movement tasks.
SK 31 takes movement or climbing risks that are unsafe r
SK 32
looks for opportunities to fall with no regard for own safety (for example, falls down -l--T -J
r
on purpose). _ __l
RG 33 loses balance unexpectedly when walking on an uneven surface. J--f
-1__--r---j
t
RG 34 bumps into things, failing to notice objects or people in the way.
MOVEMENT Raw Score
MOVEMENT Processing Comments;
CHILD Sensory Profile 2 [El 3
Almost Always = 90% or more Frequently = 75% Half the Time = 50% Occasionally = 250lo Almost Never = 100/o or less
I
BODY POSITION Processing
(-s*
g
E
([
o My child... a 0
-l
BG 35 moves stiffly,
RG 36 becomes tired easily, especially when standing or holding the body in one position r 'l-
RG
RG
37 seems to have weak muscles.
props to support self (for example, holds head in hands, leans against a wall).
l_ i-
38
39 clings to objects, walls, or banisters more than same-aged children
t---r--1
-+--+
40 walks loudly as if feet are heavy,
SK drapes self over furniture or on other people.
-f
42 needs heavy blankets to sleep.
BODY POSITION Raw Score
BODY POSITION Processing Comments:
OBAL SENSORY Processing
a-e'"
(!
(E
E o-*u (}8
g !
o)
My child... 3 n
tt I
5 4 0
43 gags easily from ceftain food textures or food utensils in mouth.
SN 44 rejects certain tastes or food smells that are typically part of children's diets.
----{
SN 45 eats only certain tastes (for example, sweet, salty).
SN 46 limits self to certain food textures.
T-r
SN 47 is a picky eater, especially about food textures.
t--
SK 48 smells nonfood objects.
-t
SK 49 shows a strong preference for certain tastes.
---+ +----
n
SK 50 craves certain foods, tastes, or smells.
1_
SK 51 puts objects in mouth (for example, pencil, hands) -
SN 52 bites tongue or lips more than same-aged children.
ORAL SENSORY Raw Score
ORAL SENSORY Processing Comments:
4 El cxrr-o sensory Pralite Z
Almost Always = 90% or more Frequently = 75% Hall the Time = 50% Occasionally = 25% Almost Never = 1 0% or less
CONDUCT Associated With Sensory Processing
L
(s
E
ro
q}&
E
g o
My child... s
RG 53 seerns accident-prone.
RG rushes through coloring, writing, or drawing.
takes excessive risks (for example, climbs high into a tree, jumps off tall furniture) that
SK 55
compromise own safety.
+--+-
SK 56 seems more active than same-aged children
RG 57 does things in a harder way than is needed (for example, wastes time, moves slowly)
58 can be stubborn and uncooperative.
59 has temper tantrums
SK 60 appears to enjoy falling.
61 resists eye contact from me or others.
CONDUCT Raw Score
CONDUCT Comments:
SOCIAL EMOTIONAL Responses Associated With Sensory Processing
(!
(g E
(,
s
o My child...
RG 62 seems to have low self-esteem (for exampie, diff culty liking self).
63 needs positive support to return to challenging situations.
64 is sensitive to criticisms.
65 has definite, predictable fears.
bo expresses feeling like a failure.
67 is too serious.
68 has strong emotional outbursts when unable to complete a task.
SN 69 struggles to interpret body language or facial expression.
70 gets frustrated easily.
71 has fears that interfere with daily routines.
72 is distressed by changes in plans, routines, or expectations
needs more protection from life than same-aged children (for example, defenseless
SN /.,
physically or emotionally).
74 interacts or participates in groups less than same-aged children.
75 has difficulty with friendships (for example, making or keeping friends)
r
I
$OCIAL EMOTIONAL Raw $core
SOCIAL EMOTIONAL Responses Comments
5
Almost Always = 90% or more Frequently = 75% Half the Time = 500/o Occasionally = 25% Almost Never = 10% or less
ATTENTIONAL Responses Associated With Sensory Processing
{-8
g
E
(u as'
o
o My child... E
4 3 ? 1 0
RG 76 misses eye contact with me during everyday interactions.
SN 77 struggles to pay attention.
SN 78 looks away from tasks to notice all actions in the room
RG 79 seems oblivious within an active environment (for example, unaware of activity).
80 stares intensively at objects.
t9
AV 81 stares intensively at people.
SK 82 watches everyone when they move around the room.
SK jumps from one thing to another so that it interferes with activities.
SN 84 gets lost easily.
has a hard time finding objects in competing backgrounds (for example, shoes in a
RG 85
messy room, pencil in "junk drawer").
ATTENTIONAL Raw Score
RG 86 seems unaware when people come into the room..
'This item is not part of the ATTENTIONAL Raw Score.
ATTENTIONAL Responses Comments:
FOR OFFICE USE ONLY
ICON KEY SCORE KEY
SK Seeking 5 Almost Always = 900/o or more
Avoiding 4 Frequently = 757o
SN Sensitivity 3 Half the Time = 50o/o
Registration 2 Occasionally = 25%
\!
No Quadrant 1 Almost Never = 1070 or less
6 El cnrr-o sensory Profite 2
