Barbara S. Bassin, OTR/L, BCP
OCCUPATIONAL THERAPY SERVICES
6509 Democracy Blvd
Bethesda, Maryland 20817
301-897-8484
www.appelbaumvision.com
SENSORIMOTOR HISTORY
Name_________________________________________
Date_____________________________
School________________________________________
Grade____________________________
NO
YES
NO
YES
NO
YES
COMMENTS
I. Tactile Sensations (touch)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Dislikes having hair washed.
Dislikes having face washed.
Dislikes having hair or nails cut.
Objects to being touched.
Seems irritable when held.
Prefers to touch rather than be touched.
Craves being touched.
Likes to touch things more than most children do.
Avoids activities that are wet or messy.
Avoids certain textures of food.
Avoids certain textures of clothing.
Fussy about the way clothes feel such as socks,
belt, seam in pants.
Bumps or pushes other children.
Isolates self from other children.
Mouths objects frequently.
II. Pain and Temperature Sensation
1.
2.
3.
Overly sensitive to pain.
Under sensitive to pain
Seems unaware of temperature, never cold.
III. Auditory Sensation (hearing)
1.
2.
3.
4.
5.
6.
7.
8.
Overly sensitive to sounds.
Needs directions repeated.
Misses some sounds.
Seems confused about the direction of sounds.
Seems distracted by sounds.
Likes to make loud noises frequently.
Has a diagnosed hearing loss.
Has history of chronic ear infections.
IV. Olfactory Sensation (smell)
1.
2.
3.
4.
Explores the environment with smell.
Frequently smells objects.
Oversensitive to certain smells.
Does not seem to notice noxious or strong odors.
V. Gustatory Sensation (taste)
1.
2.
Acts as though all food tastes the same.
Explores by putting things in the mouth.
COMMENTS
VI. Visual Skills
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Has seen an eye doctor in the past year.
Has diagnosed visual problem.
Wears glasses.
Has an eye that turns in or out.
Makes little eye contact.
Has difficulty keeping eyes on objects or target.
Has difficulty eye tracking (following with eyes).
Makes reversals when copying.
Has difficulty discriminating shapes, colors.
Appears sensitive to light.
Resists having vision blocked.
Becomes overly excited with a lot of visual stimuli.
Rubs eyes, gets headaches, or eyes water after close
work or reading.
VII. Vestibular Sensation (balance and movement)
1.
2.
3.
4.
5.
6.
Disliked being tossed in the air when younger.
Seems fearful in space (going up and down stairs,
riding teeter-totter, going on a swing).
Avoids balance activities (bike, playground
activities).
Seems sensitive to movement
a.
Gets dizzy easily.
b.
Gets sick in cars, elevators, rides.
Prefers fast moving or spinning activities.
Rocks while sitting in a chair at desk or table.
VIII. Muscle Tone
1.
2.
3.
4.
5.
6.
7.
8.
Poor standing posture.
Poor sitting posture.
Seems weaker than normal.
Seems stronger than normal
Grasps objects too tightly.
Has a weak grasp.
Tires easily.
Sits with legs in a “W” position.
IX. Coordination
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Seems accident prone.
Seems clumsy.
Frequently falls, trips, or bumps into things.
Dislikes trying new movement activities.
Difficulty learning new movement activities.
Has inconsistent hand dominance.
Manipulates small objects with difficulty.
Difficulty with pencil activities.
Avoids sports activities.
Neglects one side of body or seems unaware of it.
Falls without catching self.
Difficulty dressing and/or fastening clothes.
X. Feeding
1.
2.
3.
4.
5.
Has difficulty chewing.
Avoids chewing.
Drools.
Eats in a sloppy manner.
Difficulty handling utensils.
COMMENTS
XI. Sleeping
1.
2.
3.
Difficulty falling asleep at night.
Difficulty staying asleep at night.
Difficulty waking up.
XII. Speech and Language
1.
2.
3.
4.
5.
6.
Difficulty with articulation.
Poor use of grammar.
Stutters.
Difficulty putting thoughts into words.
Difficulty understanding the meaning of what is said.
Quiet, does not talk much.
XIII. Behavior
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Distractible.
Overly active.
Difficulty paying attention.
Fidgety.
Difficulty following directions.
Avoids play with other children.
Prefers to play alone.
Poor self confidence.
Gets mad easily (aggressive).
Cries easily.
Withdrawn.
Difficulty with transitions.
XIV. School Activities
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Avoids reading.
Loses place when reading.
Must read out loud or lip read.
Difficulty remembering what he/she read.
Reverses letters or words.
Difficulty copying from the board or paper.
Poor handwriting.
Poor spatial organization on the paper when drawing,
writing, or doing math.
Poor understanding of time concepts.
Confuses left and right.
Low grades in: Reading
Spelling
Math
Chief Concerns:
Signature:_________________________________________
Relationship to Child:_________________________________
Date:_____________________________________________