Pediatric Occupational Therapy Sensory Profile

Pediatric Occupational Therapy Sensory Profile — Form Fields

This healthcare template includes 13 fields. Sensory processing profile questionnaire for children referred to occupational therapy. Free to customize and use on ZenBuild.

• Child's Name (text, required)
• Date of Birth (text, required)
• Parent/Guardian Name (text, required)
• Parent Email (email, required)
• Referring Provider (text, optional)
• Child's Age (dropdown selection, required) — options: Under 2, 2-3 Years, 4-5 Years, 6-8 Years, 9-12 Years, 13-17 Years
• Sensory Seeking Behaviors (checkboxes, optional) — options: Constantly Moving, Craves Deep Pressure, Mouths Objects, Seeks Loud Sounds, Loves Spinning, Crashes Into Things
• Sensory Avoidant Behaviors (checkboxes, optional) — options: Covers Ears, Avoids Textures, Dislikes Being Touched, Avoids Bright Lights, Picky Eater (textures), Resists Hair Brushing/Cutting
• Areas of Difficulty (checkboxes, optional) — options: Fine Motor Skills, Handwriting, Self-Care (dressing buttons zippers), Attention and Focus, Emotional Regulation, Social Interaction, Sleep, Transitions
• School Performance Impact (dropdown selection, required) — options: No Impact, Mild Impact, Moderate Impact, Significant Impact
• Previous OT Services (multiple choice, required) — options: Yes, No
• Describe Primary Concerns (long text, required)
• What Helps Your Child Calm Down (long text, optional)