GENERAL QUESTIONS FOR EVALUATION
(Please Circle)
1.
2.
3.
4.
5.
6.
Does your child prefer their head turned to one side or the
other?
Does your child favor one arm or leg? (If yes, which one?)
________________________
Does your child favor one arm or leg? (If yes, which one?)
________________________
Does your child become very irritable at times? (If yes, when?)
________________________
Does your child prefer to stay in one position or prefer one
position to another? (If yes, which position?)
________________________
Does your child avoid certain textures of food? (If so, what
foods?)
________________________
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
7.
Does your child appear to be fearful of movement?
Yes
No
8.
Does your child seem weaker than normal?
Yes
No
9.
Does your child seem stronger than normal?
Yes
No
10.
Is your child easy to calm when upset?
Yes
No
11.
Does your child have difficulty falling asleep?
Yes
No
12.
Do your child’s movements appear awkward?
Yes
No
13.
Does your child feel stiff?
Yes
No
14.
Does your child appear clumsy?
Yes
No
15.
Does your child have difficulty with change?
Yes
No
16.
Does your child have a good attention span?
Yes
No
17.
Is your child a picky eater?
Yes
No
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