Brain Training Associates Plano TX 75093

BRAIN TRAINING ASSOCIATES, INC.
2301 Ohio Drive, Suite 130, Plano, TX 75093
(972) 964-8510 braintrain@aol.com

Please copy, complete and return either by mail or email attachment to the address above.

DALLAS SENSORY PROTOCOLS

Chilld’s Name ______________________________________________

Parents’ Names ____________________________________________

Address __________________________________________________

City_________________ State ___________ Zip__________________

Phone __________________email or FAX_______________________

cell _____________________________________________________

Previous Diagnosis _________________________________________

Date of Birth ______________________

_________Male _______ Female ________ Undetermined (CAH)

Was this a normal pregnancy and delivery? (if NO, explain)

Is the child currently on any medications? _______ If yes, which? _________________________________________________________

Did the child have ear infections or respiratory infections in infancy?______________ How often?__________________________________

Has the child had any of the following tests?

____ auditory brain stem response __ hearing ___ MRI or PET ___ amino acid screen

____ IgE allergy test __ parasite screen ___ EEG (brain) ___ X ray __ genetic screen

NOTES

________________________________________________________________________________________

LANGUAGE

Yes	No			Yes	No
		Child has not yet babbled using noises or vowel sounds	Child sometimes uses incorrect word order or changes the meaning intended
		Child has not yet babbled using consonants with vowels	Child sometimes uses incorrect words that are related in some way to the word they mean
		Child has not yet babbled using noises or vowel sounds	Child pantomimes when they can’t find a word
		Child has not yet imitated single words spontaneously	Child has difficulty making sense
		Child is not yet using single words spontaneously	Child has difficulty using verb tenses correctly
		Child is not yet combining two words spontaneously	Child has difficulty using spatial markers
		Child is not yet using two word phrases spontaneously	Child has difficulty understanding choices
		Child is not yet using simple sentences spontaneously	Child sometimes echoes what was said
		Child is not yet using sentences spontaneously	Child repeats something over and over again
		Child uses jargon (babbling) sounds for some words	Child sometimes uses pauses in place of words

VESTIBULAR FUNCTIONS

Yes	No			Yes	No
		Child appears clumsy or topples without cause	Child frequently shakes their fingers or hands
		Child has a rocking motion to gait	Child objects to tags at back of neck on clothing
		Child steps on rather than around objects on floor	Child takes clothes or shoes off constantly
		Child tends to touch a wall when walking	Child does not get dizzy after spinning
		Child tends to look down when walking	Child becomes dizzy when watching movement
		Child has difficulty following a moving object	Child grinds teeth or chews on clothing or self
		Child gets car sick	Child stands rather than sits at tables
		Child bites others without provocation	Child sits in chairs on knees or crouches
		Child seeks out spinning, pounding, or jumping	Child frequently makes high pitched noises
		Child frequently tries to get upside down	Child shakes head from side to side frequently
		Child walks or paces in circles	Child loves to climb to high places and jump off
		Child toe walks	Child taps chin or hands or flicks fingers

　AUDITORY FUNCTIONS

Yes	No			Yes	No
		Child often seems deaf or unresponsive to sound	Child frequently mutters or makes noises
		Child often ignores someone calling their name	Child is frightened or pained by some sounds
		Child often misunderstands what was said	Child uses high pitched voice inappropriately
		Child does not respond to questions	Child has a flat tone of voice
		Child seems inattentive	Child tends to drop consonants
		Child has difficulty understanding colloquial expressions	Child makes articulation errors beyond what is appropriate for age
		Child often says “huh” or “what”	Child speaks in a nasal tone of voice
		Child has difficulty understanding what they read	Child has difficulty learning to decode words

ORAL MOTOR FUNCTIONS

Yes	No			Yes	No
		Child has an aversion to certain colors or textures of food	Child has difficulty licking an ice cream cone or lollipop
		Child did not mouth objects as an infant	Child kisses without puckering lips (over 3 yrs)
		Child often chokes or has swallowing problems	Child has difficulty sucking a thick liquid from a straw
		Child has difficulty chewing	Child stuffs mouth too full when eating
		Child is aversive to someone touching their face or mouth	Child has difficulty imitating facial expressions
		Child has difficulty blowing or sucking	Child often drools

COGNITIVE FUNCTIONS

Yes	No			Yes	No
		Child ignores or does not explore new things in their environment	Child does not create scripts in doll or role play (and is at least 3 years old)
		Child’s play is repetitive and lacks variety	Child’s language decreases significantly when there is a play partner
		Child tends to hold a toy rather than playing with it	Child prefers fact books to stories
		Child explores new toys by licking, tasting, or smelling	Child seems afraid of or startled by some common objects
		Child screams frequently	Child sniffs or licks people or objects when stressed
		Child objects if a things are changed or moved	Child usually does not ask for help or information when needed
		Child insists on watching the same video many times in a row	Child often does not turn to or look at the person speaking to them
		Child seems interested in the sensory features of a video rather than the story	Child often does not look at person to whom they are speaking
		Child does not often play with action figures or dolls (and is at least 3 yrs old)	Child averts eyes to the side when a face approaches (gaze aversion)
		Child covers their ears when expecting a surprise or startling event	Child often prefers to be alone or avoids peers
		Child seems stuck on a certain type of toy or activity	Child tends to wander around a room rather than engaging in an activity
		Child ignores a play partner or objects to a play partner	Child has an aversion to certain textures or insists on certain colors of foods
		Child refuses to take turns (and is over three years old)	Child does not play board games (and is at least 5 years old)

MOTOR FUNCTIONS

Yes	No			Yes	No
		Child can NOT roll over in both directions	Child has difficulty throwing a ball (and is at least three)
		Child can NOT hold head independently	Child has difficulty swinging or had great difficulty learning to swing
		Child can NOT sit independently	Child seems floppy or weak or seemed so as an infant
		Child holds arms at waist or shoulder height when walking	Child’s muscles seem rigid or seemed so as an infant
		Child can NOT pick up objects with a palmar grasp	Child has a weak grip
		Child can NOT pick up objects with a pincer grasp	Child has difficulty balancing on an uneven or moving surface
		Child does NOT reach across midline for an object but turns or changes hands	Child can not jump with both feet (and is at least 3 years old)
		Child looks like they might fall when they run	Child climbs or descends stairs without alternating feet
		Child appears clumsy or topples without cause	Child’s foot turns in when walking
		Child has difficulty grasping a pencil or crayon	Child has difficulty climbing up and over a ladder
		Child has difficulty catching a ball (and is at least three)	Child has difficulty riding or had great difficulty learning to ride a tricycle

NEUROLOGICAL, IMMUNE, and METABOLIC FUNCTIONS

Yes	No			Yes	No
		Child has frequent headaches	Child seems excessively aware of pain or temperature
		Child has frequent rashes or hives	Child has a cyst, tumor, or other anatomical abnormality of the brain
		Child has frequent congestion	Child has an excessive desire for salt
		Child has frequent diarrhea	Child has an excessive desire for a particular type of food
		Child has frequent constipation	Child seems excessively thirsty
		Child has frequent stomach aches	Child has microcephaly, macrocephaly, or hydrocephaly
		Child has visual or hearing impairments	Child seems to ignore pain or temperature
		Child is lethargic or hyperactive	Child has a chromosomal error (translocation, deletion, etc.)
		Child has or has had difficulty gaining weight	Child has great difficulty going to sleep and staying asleep (after age 3)
		Child has an aversion to drinking water	Child has seizures or stares into space and is unresponsive at times
		Child is very short for age	Child has an aversion to some foods
		Child has frequent infections	Child vomits frequently
		Child suffered oxygen deprivation at birth	Child had a concussion or other traumatic injury to the head
		Child had heart surgery	Child had cranial facial surgery
		Child has had adenoids or tonsils removed	Child had or needs eye surgery
		Child has been treated for a metabolic disease	Child has been treated for allergies or asthma

VISUAL FUNCTIONS

Yes	No			Yes		No
		Child often looks at objects out of the corners of eyes	Child seems obsessive about looking at certain colors or patterns
		Child gazes at bright lights	Child acts blind at times
		Child gazes at moving horizontal lines like TV credits	Child does not look at a video for more than a few moments at a time
		Child’s eyes jump when following an object move	Child has difficulty reading or has headaches when reading
		Child ignores distant objects	Child does not look directly at objects
		Child places face in same plane as book when reading	Child holds objects close to the eyes
		Child likes to stare at small strings or bits of dust	Child blinks excessively
		Child has one eye that often diverges or wanders	Child’s eyes seem to cross or diverge

Yes	No	PREFRONTAL FUNCTIONS		Yes	No
		Child has difficulty learning a NEW dance or motor sequence	Child has difficulty sustaining attention on a task
		Child has difficulty controlling aggressive impulses	Child has difficulty seeing patterns and relationships
		Child has difficulty recognizing or using facial expressions	Child has difficulty understanding the pragmatic use of language
		Child has difficulty remembering faces	Child has difficulty with organization
		Child has difficulty remembering rules of behavior	Child often looks at something other than what they are talking about
		Child has difficulty remembering rules in complex games	Child has a poor sense of smell