Does your child enjoys how it feels to MOVE (Examples: Running, Dancing, Jumping)?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
2.
Does your child choose to engage in physical activities?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
3.
Your child touches or fidgets with objects in their hands? (For example: running their hands down a wall while they are walking)
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
4.
Your child can be impulsive or tends to do things in the spur in the moment?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
5.
Your child chew on shirt sleeves or collars and other non-food items?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
6.
Does your child talk loudly, hum, sing, or make other noises?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
7.
Does your child enjoy jumping, hopping, and bumping and crashing into things and people—sometimes to the point of being unsafe?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
8.
Your child only eats familiar foods?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
9.
Does your child get distracted or more hyper when their are a lot of visual distractions (busy store or somewhere there are a lot of people moving around)?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
10.
Your child needs to have distractions limited when working or doing an activity (For example, TV off or door closed)?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
11.
Your child tends to avoid activities that involve getting their hands dirty?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
12.
Does your child overreact to being touched lightly? (Pulls away, Becomes hyperactive or distressed)
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
13.
Your child has difficulty standing lines, standing close to other people, or being touched by other kids while playing?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
14.
Majority of the time, does your child seem more regulated and focused after moving and physical exercise/play?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
15.
Your child is at times wary and avoidant of swings, slides, and other playground equipment that involves excessive movement?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
16.
Does your child respond negatively or avoid certain textures? (Examples: messy play, playdough, something sandy, sticky, or slimy)
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
17.
Your child does not enjoy wearing scratchy, tight or otherwise “uncomfortable” clothes?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
18.
Your child frequently trips or bumps into things?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
19.
Your child doesn't notice when people walk into the room?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
20.
Your child doesn't seem to notice when their hands or face is dirty?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
21.
Your child takes a long time to get up in the mornings?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
22.
Your child does not seem in touch with their bodies may appear clumsy?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
23.
Does your child demonstrate low muscle tone and decreased endurance?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
24.
Is your child a picky eater?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
25.
Does your child dislike brushing their teeth, cutting their nails, or getting their hair brushed or washed?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
26.
Does your child become dizzy easily? (After playing or whenever they bend over or stand up)
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
27.
Does your child respond negatively (hyperactive, meltdowns, running away) to loud sounds?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
28.
Does your child focus on sounds that other people tend to not notice?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
29.
Does your child startle easily at unexpected or loud noises?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
30.
Does your child get distracted if there is a lot of noises around them?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
31.
Is it difficult for your child to work when there are a lot of background noises (Example: TV, Fan, Radio) ?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
32.
Does your child get agitated or hyperactive by ordinary sounds? (Blender, Toilet Flushing, Microwave, Vacuum)
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
33.
Does your child stare intensely at certain things or people?
A.
Frequently
B.
Occasionally
C.
Rarely
D.
Never
34.
During certain activities or instruction, does your child look around instead of where they are supposed to be focusing?
