DEVELOPMENTAL PATHWAYS
SENSORIMOTOR HISTORY

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SECTION 2
Child's Name Your E-Mail address

TASTE & SMELL Does child:
1. Act as though all food tastes the same Yes No Used to N/A
2. Explore with taste Yes No Used to N/A
3. Chew on non-food items Yes No Used to N/A
4. Have any feeding problems Yes No Used to N/A
5. Have trouble changing to textured foods Yes No Used to N/A
6. Sensitive to any unusual smells Yes No Used to N/A
7. Taste or smell toys, cloths, etc more than usual Yes No Used to N/A
AUDITORY (sound) Does child:
1. Have a diagnosed hearing problem Yes No Used to N/A
2. Have PE tubes in ears Yes No Used to N/A
3. Have frequent ear infections Yes No Used to N/A
4. Seem too sensitive to sound Yes No Used to N/A
5. Respond negatively to unexpected sounds Yes No Used to N/A
6. Have fears of any particular sounds Yes No Used to N/A
Describe
7. Distracted by sounds such as refrigerator, fans, fluorescent light bulbs, heaters, etc. Yes No Used to N/A
8. Miss some sounds or words Yes No Used to N/A
9. Fail to listen, or pay attention to what is said Yes No Used to N/A
10. Seem to be confused about what direction sounds come from Yes No Used to N/A
11. Like to make loud noises Yes No Used to N/A
12. Like to sing and/or dance to music Yes No Used to N/A
13. Have difficulty copying rhythmic sounds Yes No Used to N/A
14. Fail to follow through to act upon requests to do something, to understand directions Yes No Used to N/A
15. Unable to function if 2 or 3 steps of instructions are given at once Yes No Used to N/A
16. Talk excessively Yes No Used to N/A
17. Talking interferes with his/her listening Yes No Used to N/A
18. Have a delay in speech development Yes No Used to N/A
MUSCLE TONE Does child:
1. Feel heavier than he/she looks Yes No Used to N/A
2. Have good endurance Yes No Used to N/A
3. Have any diagnosed muscle problems Yes No Used to N/A
4. Have flat feet Yes No Used to N/A
5. Slump when sitting Yes No Used to N/A
6. Get tired easily Yes No Used to N/A
7. Seem generally weak Yes No Used to N/A
8. Keep mouth open Yes No Used to N/A
9. Prefer to lie on back rather than stomach Yes No Used to N/A

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