Sensorimotor History Questionnaire For Parents of Preschool Children

Lynn A. Balzer-Martin, Ph.D., OTR

Your responses will probably be most accurate if you first read all the statements below the question, checking off those that describe your child. Then, circle "YES" if you have checked one or more statements; circle "NO" if none applies.

 

1. Is your child particularly sensitive to touch?      YES     NO

· Did not always find touch to be calming or pleasurable as an infant.

· Is more annoyed than other children the same age by a shampoo or face wash.

· Reacts negatively to a haircut or having nails cut.

· Is very picky about textures of clothing.

· Is very fussy about clothing, e.g., dislikes collars or turtlenecks; is very annoyed by labels; often complains about socks, coats, or hats; prefers only loose clothing.

· Is uncomfortable in long sleeves or pants; prefers as little clothing as possible.

· Prefers long sleeves and pants, even in warm weather.

· Avoids messy activities such as play dough, clay, mud pies, finger paints and cooking.

· Overreacts to physically painful experiences.

· Underreacts to physically painful experiences.

· Tends to withdraw from a group, or to bump or push others in a group; is irritable in close quarters.

 

2. Does your child particularly enjoy fast-moving or spinning activities at the playground or at home, perhaps with little or no dizziness?      YES     NO

· Likes to swing very high and fast/or for long periods of time.

· Frequently rides the playground merry-go-round.

· Especially likes movement experiences at home such as bouncing on furniture, using a rocking chair, or being turned in a swivel chair.

· Enjoys getting into an upside-down position (feet up, head down).

· Likes games where vision is occluded, such as putting a bandana over eyes, a bag over head, or just keeping eyes closed for fun.

· Enjoys most the fast and spinning amusement park rides.

 

3. Does your child show particular caution in approaching activities involving fast movement or movement of the body through space?     YES      NO

· Tends to avoid swings or slides or uses them with hesitation.

· Does not like riding a seesaw or going up and down an escalator.

· Is cautious about heights and climbing.

· Enjoys movement that s/he initiates but does not like to be moved by others, particularly if the movement is unexpected.

· Dislikes trying new movement activities or has difficulty learning them.

· Has difficulty climbing or descending stairs or hills.

· Tends to get motion sick in a car, airplane or elevator.

 

4. Does your child have unusual sensitivities to smell?      YES     NO

· Has difficulty identifying things by their smell.

· Tends to complain that fairly normal odors are unpleasant.

· Tends to ignore unpleasant odors when they are present.

 

5. Is your child particularly sensitive to noise, e.g., putting hands over ears when others are not bothered by sounds?     YES      NO

 

6. Have you ever had concerns regarding your child's hearing?      YES     NO

 

7. Have you ever had concerns regarding your child's speech and/or language skills?     YES     NO

 

8. Have you ever had concerns regarding your child's eyesight or visual functioning?     YES     NO

 

9. Does your child have a more "loose" or "floppy" body build than others?     YES      NO

· Tends to slump in chair or sprawl over chair and table.

· Does not feel very "firm" when you lift child up or move child's limbs to dress.

· Has difficulty turning knobs or handles that require some pressure.

· Fatigues easily during family outings or during physical activities.

· Has a loose grasp on objects such as a pencil, spoon or something s/he carries.

· Has a tight, tense grasp on objects (to compensate for underlying looseness).

 

10. Can your child easily orient his/her body effectively for dressing activities, such as putting arms in sleeves, fingers in mittens or toes in socks?      YES     NO

 

11. Do you feel that your child (age 4 and up) has already established a definite hand preference when using a crayon, marker, pencil, etc.?      YES     NO

 

12. Does your child spontaneously engage in active physical games involving running, jumping and use of large play equipment?     YES      NO

 

13. Does your child spontaneously seek out activities requiring manipulation of small objects?     YES     NO

· Enjoys Duplo, Legos.

· Enjoys building with blocks.

· Enjoys arts and crafts projects using small objects, such as beads, straws, buttons, felt, cotton balls, etc.

 

14. Does your child spontaneously choose to do activities involving the use of "tools" such as crayons, pencils, markers, scissors, etc.?      YES     NO

 

15. Do you feel that your child has an adequate attention span for things that s/he enjoys?     YES     NO

 

16. Do you feel that your child tends to be restless or "fidgety" during times when quiet concentration is required?      YES     NO

 

17. Has your child had difficulty regulating sleep patterns?      YES     NO

· Took longer than other infants to sleep through the night.

· Had colic as a baby.

· Never took naps, or gave up naps sooner than most children.

· Now has difficulty falling asleep.

· Still does not consistently sleep through the night.

 

18. Has your child had any of the following?      YES     NO

· Frequent ear infections

· Allergies

· Serious illness or surgery

If YES, please explain:

 

19. Please share any other characteristics of your child that you think it would be appropriate for us to know.  Thank you.

 

The screening manual for the Balzer-Martin Preschool Screening Program is available for purchase. To order, contact St. Columba's Nursery School:
BAPS
St. Columba's Nursery School
4201 Albemarle Street, NW
Washington, DC 20016
email: school@columba.org