Occupational therapy screen sensory and movement

Name Required

NHS number

Date of birth Required

Completed by (if not client)

Date Required

Team

Sensory differences

Please score each statement as indicated and add extra information where relevant.

I always notice how food feels in my mouth. This is more important to me than how it tastes. Required

I am very sensitive to the way my clothes feel when I touch them. How they feel is more important to me than how they look. Required

I am picky about what I wear because I don't like how certain textures feel on my skin. Required

The same sound, colour or texture can suddenly change from very sensitive to very dull. Required

I often feel the lights are too bright in some places. Required

Fluorescent lights bother me. Required

I cannot listen to someone talking to me if there is any background noise at all. I can't 'tune out' the background. Required

I avoid situations that involve certain sounds (e.g. bells, whistles, buzzers, high pitched sounds, crowds of people talking). Required

I don't even notice sounds that seem to bother other people. Required

I cannot stand to be around certain smells (perfumes, cleaning products) Required

I don't notice odours that seem to bother others (e.g. something rotting in the fridge will be missed by me but not the person I live with). Required

Sometimes the sound of a word or a high-pitched noise can be painful to my ears. Required

I avoid some foods because I can't stand the texture, even if the taste is ok. Required

Most foods taste bland to me- eating brings me no particular pleasure. Required

When I feel overwhelmed by my senses, I have to isolate myself to shut them down. Required

People are surprised by the things I wear in winter- I don't feel the cold the way others do, and sometimes I go out with no coat or wearing shorts. Required

I don't seem to notice when it is hot outside- I have to be told by someone else when to stop wearing my winter coat in Spring. Required

I do certain things with my hands over and over again (like flapping, twirling sticks or strings, waving things by my eyes). Required

Sometimes I have to cover my ears to block out painful noises (like vacuum cleaners or people talking too much or too loudly). Required

Sometimes things that should feel painful are not (for instance when I hurt myself or burn my hand on a stove). Required

It calms me to spin around or to rock in a chair when I am feeling stressed. Required

If I am in a place where there are many smells, textures to feel, noises or bright lights, I feel anxious or frightened. Required

The same sound sometimes seems very loud or very soft, even though I know it has not changed. Required

I can't tolerate things I dislike (like smells, textures, sounds or colours). Required

I don't like to be hugged or held. Required

When I go somewhere, I have to follow a familiar route or I can get very confused and upset. Required

Extra information regarding any of the above answers (If needed) Required

Movement differences

I often feel unsteady on my feet- as if I am going to tip over. Required

I avoid certain kinds of motion (e.g. won't sit on a swing, can't ride backwards on the train). Required

I often feel clumsy because I drop things and trip over things a lot. Required

I have never been good at sports involving a ball. Required

I can't seem to sit still, and my restlessness sometimes causes problems for me. Required

I have trouble getting tasks started. Required

I have never been good with my hands - I can't use tools to fix things. Required

People tell me I am rocking when I sit for a long time, but I am not even aware I am doing it. Required

I can't carry two things at a time without dropping something. Required

My handwriting is so hard for others to read that I try to avoid it altogether. Required

I sometimes catch myself flapping my hand or flicking my fingers, especially when I am feeling tense or overloaded. It is a habit I can't seem to break. Required

I feel I have to move about a lot otherwise I won't feel right. Required

Extra information regarding any of the above answers (If needed)

These sensory/movement differences are a problem for me in everyday life because...

My sensory differences are helpful/beneficial because...

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