Winnie Dunn Ph D OTR FAOTA Caregiver Questionnaire

Winnie Dunn Ph D Otr Faota Caregiver Questionnaire-Free PDF

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Responds negatively to unexpected or loud noises for example cries or hides at. noise from vacuum cleaner dog barking hair dryer,Holds hands over ears to protect ears from sound. Has trouble completing tasks when the radio is on, Is distracted or has trouble functioning if there is a lot of noise around. Can t work with background noise tor example fan refrigerator. Appears to not hear what you say lor example does not tune in to what you. say appears to ignore you, Doesn t respond when name is called but you know the child s hearing is OK. Enjoys strange noises seeks to make noise for noise s sake. Section Raw Score Total, Expresses discomfort with or avoids bright lights for example hides from sunlight. through window in car,Happy to be in the dark, Becomes frustrated when trying to find objects in competing backgrounds.
for example a cluttered drawer, Has difficulty putting puzzles together as compared to same age children. Is bothered by bright lights after others have adapted to the light. Covers eyes or squints to protect eyes from light, looks carefully or intensely at objects people for example stares. Has a hard time finding objects in competing backgrounds ior example shoes in a. messy room favorite toy in the junk drawer,Section Raw Score Total. L 19 Dislikes activities where head is upside down for example somersaults roughhousing. L 20 Avoids playground equipment or moving toys for example swing set merry go round. L 21 Dislikes riding in a car, Holds head upright even when bending over or leaning for example maintains a. rigid position posture during activity, L 23 Becomes disoriented after bending over sink or table for example falls or gets dizzy.
Seeks all kinds of movement and this interferes with daily routines for example. can t sit still fidgets, Seeks out all kinds of movement activities for example being whirled by adult. merry go rounds playground equipment moving toys, H 26 Twirls spins self frequently throughout the day for example likes dizzy feeling. H 27 Rocks unconsciously for example while watching TV. 7 H 28 Rocks in desk chair on floor,Section Raw Score Total. Ct Avoids getting messy lor example in paste sand finger paint glue tape. Expresses distress during grooming for example figh s or cries during haircutting. face washing fingernail cutting, Ct L 31 Prefers long sleeved clothing when it is warm or short sleeves when it is cold. Ct I 32 Expresses discomfort at dental work or toothbrushing for example cries or fights. Ct I 33 Is sensitive to certain fabrics for example is particular about certain clothes or bedsheets. Ct L 34 Becomes irritated by shoes or socks, Ct I 35 Avoids going barefoot especially in sand or grass.
Ct L 36 Reacts emotionally or aggressively to touch. Ct L 37 Withdraws from splashing water, Ct I 38 Has difficulty standing in line or close io other people. Ct L 39 Rubs or scratches out a spot that has been touched. Ct H Touches people and objects to the point of irritating others. Displays unusual need for touching certain toys surfaces or textures for example. constantly touching objects,Ct H Decreased awareness OJ pain and temperature. Cl H Doesn t seem to notice when someone touches arm or back ior example unaware. Ct H 44 Avoids wearing shoes loves to be barefoot,Ct H 45 Touches people and objects. Ct H 46 Doesn t seem to notice when face or hands are messy. Section Raw Score Total,Item I E Multisensory Processing. 47 Gels lost easily even in familiar places,48 Has difficulty paying attention.
L 49 Looks away from tasks to notice all actions in the room. 3 H 50 Seems oblivious within an active environment tor example unaware of activity. A H 51 Hangs on people furniture or objects even in familiar situations. A H 52 Walks on toes,Ct H 53 Leaves clothing twisted on body. Section Raw Score Total, L 55 Avoids certain tastes or food smells that are typically part of children s diets. L 56 Will only eat certain tastes list, L 57 Limits self to particular food textures temperatures list. L 58 Picky eater especially regarding food textures. H 59 Routinely smells nonfood objects, H 60 Shows strong preference for certain smells list. H 61 Shows strong preference for certain tastes list. H 62 Craves certain foods list,H 63 Seeks out certain tastes or smells list.
H 64 Chews or licks on nonfood objects,H 65 Mouths objects for example pencil hands. Section Raw Score Total, t H 67 Tires easily especially when standing or holding particular body position. t H 68 Locks joints for example elbows knees for stability. t H 69 Seems to have weak muscles,t H 70 Has a weak grasp. t H 71 Can t lift heavy objects for example weak in comparison to same age children. t H 72 Props to support self even during activity,7 H 73 Poor endurance tires easily. 7 H 74 Appears lethargic for example has no energy is sluggish. Section Raw Score Total, 76 Hesitates going up or down curbs or steps for example is cautious slops before moving.
L 77 Fears falling or heights, L 78 Avoids climbing jumping or avoids bumpy uneven ground. 7 L 79 Holds onto walls or banisters for example clings. H 80 Takes excessive risks during play for example climbs high into a tree jumps off tall furniture. H 81 Takes movement or climbing risks during play that compromise personal safeiy. H 82 Tums whole body to look at you, 1 H 83 Seeks opportunities to fall without regard to personal safeiy. 1 H 84 Appears to enjoy falling,Section Raw Score Total. L 85 Spends most of the day in sedentary play for example does quiet things. I 86 Prefers quiet sedentary play for example watching TV books computers. L 87 Seeks sedentary play options,7 L 88 Prefers sedentary activities. H 89 Becomes overly excitable during movement activity. H 90 On the go,H 91 Avoids quiet play activities,Section Raw Score Total.
Needs more protection from life than other children for example defenseless. C physically or emotionally,f L Rigid rituals in personal hygiene. C H 94 Is overly affectionate with others, C H 95 Doesn t perceive body language or facial expressions for example unable to interpret. Section Raw Score Total,H 97 Stares intensively at objects or people. H 98 Watches everyone when they move around the room. H 99 Doesn t notice when people come into the room. Section Raw Score Total, C Seems to have difficulty liking self for example low self esteem. C 101 Has trouble growing up for example reacts immaturely to situations. C 102 Is sensitive to criticisms, C 103 Has definite fears for example fears are predictable.
C 104 Seems anxious, C 105 Displays excessive emotional outbursts when unsuccessful at a task. C 106 Expresses feeling like a failure,C 107 Is stubborn or uncooperative. C 108 Has temper tantrums,C 109 Poor frustration tolerance. C 110 Cries easily,C 111 Overly serious, C 112 Has difficulty making friends for example does not interact or participate in group play. C 113 Has nightmares,C 114 Has fears that interfere with daily routine.
C 115 Doesn t have a sense of humor,C 116 Doesn t express emotions. Section Raw Score Total,Writing is illegible, Has trouble staying between the lines when coloring or when writing. Uses inefficient ways oi doing things for example wastes time moves slowly. does things a harder way than is needed, L Has difficulp tolerating changes in plans and expectations. L Has difficulty tolerating changes in routines,Section Raw Score Total. H 124 Deliberately smells objects,H 125 Does not seem to smell strong odors.
Section Raw Score Total,FOR OFACE USE ONLY,ICON KEY THRESHOLD KEY SCORE KEY. Auditory NeHher low nor high 1 Always,L low 2 Frequently. H High 3 OccaSIOnally,TastelSmeH 4 Seldom,Position 5 Never. L 19 L 20 L 21 L 22 L 23 H 24 H 25 H 26 H 27 7 H 28 Comments Dislikes activities where head is upside down for example somersaults roughhousing Avoids playground equipment or moving toys for example swing set merry go round

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