The following is a brief questionnaire for parents and caregivers of children who may suspect that their children are struggling in their current settings. Remember, this is only a questionnaire, not a complete diagnostic assessment tool.

Answer these questions keeping in mind that you want to compare your son or daughter with what you feel the average child his or her age is experiencing. Also consider the duration of the symptoms. If the symptoms have been taking place for less than 6 months this could be a sign of another problem such as depression, anxiety or just stress in general. Please consider these factors as you complete this questionnaire.

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Tell Us About Your Child
Bothered by textures on body face or hands, having nails cut, hair combed
Bothered by background noise, loud, unexpected sounds
Avoids movement activities (swings, climbing, playground activities)
Doesn't feel pain, doesn't notice when touched
Avoids eye contact
Unaware of body sensations such as hunger, hot, cold, need to use toilet
Doesn't seem to notice sensory stimuli (smells, noisy crowded places)
Constantly on the move, seeks intense crashing or rough play
Has difficulty sitting still, wiggles a lot, especially if trying to pay attention
Makes disruptive noises or sounds
Has poor balance, falls easily, avoids balance related activities (bike riding)
Has poor endurance, is weak and gets tired easily, avoids physical activity
Slumps when sits in a chair or on the floor, uses arms / hands to support self
Difficulty learning new motor activities or those requiring steps
Clumsy, awkward, accident prone, bumping into people or objects
Difficulty organizing / takes a long time to perform daily life tasks
Difficulty organizing / takes a long time to perform daily life tasks
Struggles with fine motor skills (hand writing)
Dislikes or avoids group sports
Visual difficulty: often loses place, eyes skip one or more lines
Cannot follow directions in a noisy environment
Has difficulty completing puzzles
Has difficulty identifying different sounds or letters
Has difficulty judging force required for a task
Cannot find pictures hidden in background
Difficulty finding numbers or words on page (especially math or reading tasks)
Irritable, short tempered
Easily overwhelmed, frustrated by daily life activities
Does not transition smoothly from one activity to another
Has difficulty making and keeping friends
Does not sleep well, can't get enough rest
Lacks confidence with new environments and new tasks
Has frequent mood fluctuations
Is not affectionate, not touching or hugging
Is needy, lacks independence, low self-reliance, low self esteem
Lack of tactfulness, acts impulsively
Response to situations appears immature for age
Anxious, bites nails, face and body not relaxed
Is distracted easily, not able to stay on task
Has poor short term memory
Must re-read schoolwork several times to comprehend
Has difficulty finding clothes, getting dressed in the a.m.
Planning ahead is difficult, prefers to avoid planning at all
Disorganized with school assignments, belongings, schedule
Can't remember sequential tasks – do A, then B, then C
Often fails to begin or to complete tasks or projects unless helped
Difficulty following what others are saying
Misuses or confuses words or sounds
Needs instructions repeated, needs visual cues (What? Huh?)
Difficult to understand, can't speak clearly
Difficulty with spelling
Unable to recognize or repeat rhymes or songs
Does not like to sing or hum
Difficulty interpreting tone of voice (angry vs. joking)
Tendency to ramble, can't “get to the point”
Poor grammar, doesn't speak in complete sentences
Mumbles, has monotone voice
Slow to react to speech
Needs to be given directions repeatedly before responding
Lack of understanding what is said, needs explanations