DALLAS SENSORY PROTOCOLS

Child's Name______________________________ Parents' Names_______________________

Address______________________________________________________________________

City, State ___________________________ Zip _____________________________________

Phone _________________email or FAX____________________cell_____________________

Previous Diagnosis ________________________ given by______________________________

Date of Birth ___________ Male _______ Female ________ Still Undetermined _______

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 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

If any of the above tests were checked, please give the reason that the child was tested, their age at testing, and the results of the test:

THE FOLLOWING ITEMS ARE SYMPTOMS OF IMPAIRMENT

PLEASE CHECK YES IF THE ITEM IS TRUE OF YOUR CHILD

IF A QUESTIONS DOES NOT APPLY TO YOUR CHILD CHECK NO

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 sometimes pantomimes when they can't find a word
		Child has not yet imitated single words spontaneously	Child has difficulty making sense when recounting an event
		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 (on, over, through)
		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 (4-5 words) 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 flicks their fingers or tap their palms
		Child has a rocking gait	Child objects to tags at back of neck on clothing
		Child steps on rather than over objects	Child takes clothes or shoes off constantly
		Child tends to touch a wall, railing, etc, when walking	Child becomes dizzy when watching movement or when walking
		Child tends to look down when walking	Child does not get dizzy after spinning
		Child has difficulty following a moving object	Child is aversive to touch on the mouth or face (and was never intubated)
		Child gets car sick	Child tends to stand rather than sit to eat
		Child averts their eyes to the side when walking down a hall	Child is obsessive about swinging, spinning, or bouncing
		Chld 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 loves to climb to high places and jump off	Child walks or paces in circles
		Child slams into furniture or people	Child sits on knees or keeps their feet on chair seats
		Child bites others WITHOUT provocation	Child grinds teeth
		Child toe walks	Child taps on their chin

AUDITORY FUNCTIONS

Yes	No			Yes	No
		Child often seems deaf or unresponsive to sound	Child frequently mutters or makes noises
		Child often ignores their name	Child is frightened or pained by some sounds
		Child often doesn't understand what is said	Child uses high pitched voice inappropriately
		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"?	Child has a nasal tone
		Child has difficulty with reading comprehension	Child has difficulty learning to decode words

ORAL MOTOR FUNCTIONS

Yes	No			Yes	No
		Child has an aversion to certain food textures	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 prefers fact books to story books
		Child explores new toys by licking, tasting, or smelling (over 3 yrs)	Child's language decreases significantly when there is a play partners
		Child usually does not ask for help or information when needed	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 often prefers to be alone or avoids peers
		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 not the story	Child often does not look at person to whom they are speaking
		Child does not often play with action figures or dolls (over 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 tends to wander
		Child seems stuck on a certain type of activity	Child ignores a play partner or objects to a play partner
		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
		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 ld)
		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 rashes	Child has frequent headaches
		Child is frequently congested	Child has had difficulty gaining weight
		Child has frequent diarrhea	Child has an aversion to drinking water
		Child has frequent constipation	Child has been treated for a metabolic disease
		Child has frequent stomach aches	Child has had adenoids or tonsils removed
		Child is lethargic or hyperactive	Child has frequent infections
		Child is short for age	Child has been treated for allergies or asthma

PREFRONTAL FUNCTIONS

Yes	No			Yes	No
		Child has difficulty learning a NEW dance or motor sequence	Child has difficulty sustaining attention on a task
		Child has difficulty controlling aggressions	Child has difficulty seeing patterns and relationships
		Child has difficulty recognizing or using facial expressions	Child has difficulty understanding expressions of speech
		Child has difficulty remembering faces	Child has difficulty with organization
		Child has difficulty remembering rules of behavior or complex rules in a game	Child often looks at something other than what they are talking about

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 will only look at a video briefly	Child's eyes jump when following an object move
		Child gazes at moving horizontal lines (e.g.film credits)	Child has difficulty reading or has headaches when reading
		Child does not look directly at objects	Child ignores distant objects
		Child holds objects close to the eyes	Child places face in same plane as book when reading
		Child blinks excessively	Child likes to stare at small strings or bits of dust
		Child's eyes seem to cross or diverge	Child has one eye that often diverges or wanders