DALLAS SENSORY PROTOCOLS

Chilld’s Name _____________________________________________________________

Parents’ Names ___________________________________________________________

Address _________________________________________________________________

City_______________________________ State ___________ Zip__________________

Phone ___________________email or FAX______________________________________

cell _____________________________________________________________________

Previous Diagnosis  ________________________________________________________

Date of Birth ______________________ _______Male   ______ Female   _______ 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 and at what age?_________________________________________________

Has the child had any of the following tests?

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

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

Stage of Play ____________________________________________________________

Stage of Language ________________________________________________________

If a statement below is TRUE, then mark YES; if it is FALSE or DOES NOT APPLY, answer NO.

LANGUAGE

YES	NO
		Does not use noun+adjective spontaneously (NOT echoed or cued)
		Does not use short phrases spontaneously (NOT echoed or cued)
		Does not use spontaneous sentences (not echoed or cued)
		Sometimes uses made-up words in place of real words
		Often can't find words and uses gestures instead to communicate
		Often gets word order wrong
		Often uses a wrong (but related) word when talking
		Has difficulty using past, future or imperfect tenses or only uses the present tense
		Often confuses spatial words (e.g. through, over, between, behind)
		Has difficulty initiating speech or conversation
		Frequently has to look away from a face when speaking or listening
		Frequently echoes part or all of what a speaker said
		Has difficulty making sense when explaining or describing
		Has a weak voice or a very loud voice
		Makes articulation errors beyond what would be expected for age

 

VESTIBULAR FUNCTIONS

YES	NO
		Seems clumsy or topples when walking or running
		Walks with a side-to-side rocking motion
		Tends to step on rather than around objects on floor
		Tends to want to touch a wall when walking
		Tends to keep their head down when walking
		Eyes lose target when tracking a moving object (visual pursuit)
		Seems to get car sick easily or avoids looking out a window in cars
		Seeks out spinning, pounding, or jumping
		Walks on their toes frequently
		Has rapid mood swings
		Has difficulty eating or swallowing
		Has difficulty calming down after getting upset
		Often walks or paces in circles
		Often flicks their hands or fingers or flaps their hands
		Often licks lips, makes facial grimaces or makes sounds in the throat
		Seems to have difficulty with hand-eye coordination
		Has difficulty going to sleep or staying asleep

 

　AUDITORY FUNCTIONS

YES	NO
		Often seems deaf or unresponsive to sound
		Often ignores someone calling their name
		Frequently mutters or makes noises
		Seems frightened or pained by some sounds
		Often misunderstands what was said
		Frequently ignores questions directed to them
		Has a flat or very nasal tone of voice
		Often seems inattentive
		Seems to confuse or drop certain consonants
		Has difficulty understanding expressions of speech
		Has difficulty understanding what they read
		Has difficulty understanding a speaker if there is background noise
		Tends to stop speaking when someone else begins to talk
		Has difficulty listening if there is a competing conversation (e.g. at a party)

 

ORAL MOTOR FUNCTIONS

YES	NO
		Has an aversion to certain colors or textures of food
		Has difficulty licking
		Kisses without puckering lips (over 3 yrs)
		Tends to choke frequently
		Has difficulty sucking a thick liquid from a straw
		Stuffs mouth too full when eating
		Has difficulty blowing a bubble or blowing out a candle
		Often drools
		Has difficulty biting with the front teeth
		Tends to spit when talking

 

COGNITIVE FUNCTIONS

YES	NO
		Explores new objects by licking, tasting, or smelling
		Throws frequent fits or tantrums
		Objects if something is changed or moved
		Seems more interested in the visual aspects of a video than the story
		Never played with dolls or action figures by making them talk to each other
		Covers ears when expecting a surprise or startling event
		Prefers fact books to stories
		Seems afraid of or startled by some common objects
		Rarely asks for help or information
		Prefers to be alone or avoids peers
		Seems stuck on a certain type of toy or activity

 

MOTOR FUNCTIONS

YES	NO
		Holds arms at waist level when walking
		Has difficulty grasping objects with a pincer grasp (thumb and first finger)
		Has difficulty pointing, counting on fingers or isolating individual fingers
		Turns or changes hands rather than crossing midline
		Has difficulty grasping a pencil or crayon
		Has difficulty throwing or catching a ball
		Seems to have weak muscle tone (low tone)
		Seems to have rigid muscles (high tone)
		Has a weak grip
		Climbs or descends stairs without alternating feet
		One foot turns in when walking

 

NEUROLOGICAL, IMMUNE, AND METABOLIC FUNCTIONS

YES	NO
		Has frequent headaches
		Has frequent congestion, rashes or hives
		Has allergies
		Has a vision or hearing impairment
		Has cortical visual or hearing impairment (auditory or visual processing disorder)
		Seems hyperactive
		Seems excessively tired or lazy
		Has had a brain injury
		Vomits frequently
		Has encephalopathy or a neuropathy (abnormal brain)

 

VISUAL FUNCTIONS

YES	NO
		Often looks at objects out of the corners of eyes
		Gazes at bright lights
		Avoids light, squints frequently or is photosensitive
		Gazes at moving horizontal lines like TV credits
		Seems obsessive about looking at certain colors or patterns
		Acts blind at times
		Looks away from moving objects or won't watch television
		Has difficulty reading or has headaches when reading
		Ignores distant objects or brings objects close to the eyes
		Places face in same plane as book when reading
		Does not look directly at objects or uses side vision
		Likes to stare at small strings or bits of dust
		Blinks excessively
		Eyes seem to cross or diverge
		Pokes or presses their eyes
		Looks away from what their hands are doing
		Eyes bulge or are sunken
		Has retinopathy or other visual abnormalities

 

PREFRONTAL/FRONTAL LOBE FUNCTIONS

YES	NO
		Has difficulty learning a NEW motor sequence
		Has difficulty sustaining attention on a task
		Has difficulty inhbiting impulses
		Has difficulty seeing how something is similar or related
		Has difficulty understanding the pragmatic meaning of language
		Has difficulty with organization
		Perseverates (continues to do or talk about the same thing)
		Has difficulty understanding social expectations or rules
		Has difficulty learning from context
		Has surprising, or seemingly inappropriate responses at times
		Seems to respond with aggression or hostility in situations where peers do not
		Has rigid or odd rules and insists that others follow them