DEVELOPMENTAL PATHWAYS
SENSORIMOTOR HISTORY

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SECTION 3
Child's Name Your E-Mail address

COORDINATION Does child:
1. Sit, stand or walk late Yes No Used to N/A
2. Sit, stand or walk early Yes No Used to N/A
3. Was creeping/crawling phase unusually long Yes No Used to N/A
4. Was creeping/crawling phase basically omitted Yes No Used to N/A
5. Are movements slow, prodding, deliberate Yes No Used to N/A
6. Play with toys appropriately for age Yes No Used to N/A
7. Have difficulty with sequential tasks; dressing buttoning, zipping, shoe tying Yes No Used to N/A
8. Clumsy playing with toys Yes No Used to N/A
9. Have difficulty learning to hold a pencil or crayon in a 3-point position Yes No Used to N/A
10. Creep on tummy or bottom Yes No Used to N/A
11. Trip or fall alot Yes No Used to N/A
12. Seem clumsy, awkward Yes No Used to N/A
13. Bump into things alot Yes No Used to N/A
14. Have a dominant hand Yes No Used to N/A
15. Have poor handwriting Yes No Used to N/A
16. Handle small things easily Yes No Used to N/A
17. Eat neatly for age Yes No Used to N/A
18. Have rigid movements Yes No Used to N/A
19. Grimace or use tongue in fine motor tasks Yes No Used to N/A
20. Get shaky in fine motor tasks Yes No Used to N/A
21. Enjoy sports, gym, etc Yes No Used to N/A
VESTIBULAR (movement) Does Child
1. Arch back when held or moved Yes No Used to N/A
2. Enjoy being rocked Yes No Used to N/A
3 Like being tossed in the air Yes No Used to N/A
4. Like fast spinning carnival rides Yes No Used to N/A
5. Like to swing Yes No Used to N/A
6. Spin or whirl more than other children Yes No Used to N/A
7. Get carsick easily Yes No Used to N/A
8. Get nauseous and/or vomit from other movement experiences Yes No Used to N/A
9. Rock while sitting Yes No Used to N/A
10. Jump alot Yes No Used to N/A
11. Have fear in space (stairs, heights) Yes No Used to N/A
12 Lose balance easily Yes No Used to N/A
13. Walk on toes (not flat feet) Yes No Used to N/A
14 Misunderstand meaning of words used in relation to movement or position Yes No Used to N/A

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