Form OT-Q

Form OT-Q: OT / SPD Questionnaire

Please complete this form to the best of your ability. If you are not able to answer a question or do not know the answer, please indicate "NA" for not applicable/not available.

Client Name

Client DOB

Parent/Guardian (A)

P/G Email (A)

OT/SPD QUESTIONNAIRE

Instructions:
X to mark items that currently apply
XX (Double X) items which are of particular concern
P to mark items that were formerly a problem (but no longer are)
(n/a) or leave items blank that don't apply

A. VESTIBULAR PROCESSING (MOVEMENT AND BALANCE)

Becomes overly excited after movement activity

N/A

Thrill seeker on the playground

N/A

Avoids movement equipment on playground, prefers to play on

N/A

Seeks intense movement; spins, rocks, twirls, bounces, jumps

N/A

Shakes head vigorously, assumes upside down position frequently

N/A

Uncomfortable on elevators, escalators, motion sickness

N/A

Excessive dizziness or nausea from swinging, spinning, riding in car

N/A

Preoccupied with movement activities, can’t sit still

N/A

Avoids activities which require balance/loses balance easily

N/A

Poor negotiation on uneven terrain

N/A

As infant, tended to arch back when held or moved

N/A

Avoids activities in which feet leave the ground

N/A

Fearful of simple challenges to balance

N/A

Trips easily, clumsiness

N/A

Fear of heights, climbing, fear of falling when no real danger exists

N/A

Hesitant when climbing or descending stairs (seeks hand, railing, or walls)

N/A

Dislikes being moved

N/A

Protests head being tipped backward

N/A

Fearful of being tossed in air or turned upside down

N/A

Bumps head often: doesn’t extend arms when pushed from behind

N/A

Often holds head, neck, and shoulders stiffly

N/A

Holds head upright when bending over or leaning (dislikes somersaults)

N/A

B. PROPRIOCEPTIVE FUNCTION (BODY AWARENESS)

Difficulty controlling movement, uses too little or too much power/force

N/A

Insecure regarding body movement

N/A

Poor posture/postural instability

N/A

Props head on hand or forearm

N/A

Prefers/avoids crunchy or chewy foods

N/A

Difficulty changing positions or moving slowly

N/A

Avoids/seeks vibratory stimulation (barber’s clippers, electric toothbrush, vibrating toy)

N/A

Craves tumbling or wrestling

N/A

Frequently gives or requests firm or prolonged hugs

N/A

Seeks out adults when on playground

N/A

Walks on toes frequently

N/A

Drags feet or poor heel-toe pattern when walking

N/A

Wide-base stance

N/A

Turns whole body to look at person or object

N/A

Moves stiffly, head, neck, shoulder rigidity

N/A

Plays roughly with people or objects

N/A

Bumps into things

N/A

Avoids participation in ordinary movement experiences

N/A

Resists new physical challenges, saying “I can’t” without attempting

N/A

Seems weaker or tires more easily than peers

N/A

Appears lethargic

N/A

Seeks sedentary play

N/A

Leans on objects or people for stability

N/A

Weak pencil grasp, little pencil pressure

N/A

Cannot lift heavy objects

N/A

Moves with quick bursts of activity rather than sustained movement

N/A

Achieves standing posture by pushing off floor with hands

N/A

Joints extremely flexible

N/A

Collapses onto furniture

N/A

Avoids “heavy work” activities

N/A

Seeks opportunities to fall, crashes into things

N/A

Stamps or slaps feet on ground when walking

N/A

Kicks heels against floor or chair

N/A

Bangs stick or other object along wall or fence when walking

N/A

Cracks knuckles

N/A

Grinds teeth, bites or chews objects, clothing

N/A

C. TACTILE PROCESSING (TOUCH)

Excessive reaction to light touch sensations (anxiety, hostility, aggression) as infant, not calmed by cuddling/stroking

N/A

Difficulty standing in line or close to other people

N/A

Stands too close to people to the point of irritation

N/A

Tenses when patted affectionately

N/A

Negative reaction to unseen, unexpected touch

N/A

Clothes cover whole body, regardless of weather

N/A

Wears minimal clothes, regardless of weather

N/A

Avoids certain textures of clothing, materials

N/A

Avoids putting hands in messy substances/getting dirty

N/A

Engages in self-injurious behaviors. List

N/A

Likes to be wrapped tightly in sheet or blanket

N/A

Seeks tight spaces

N/A

Engages in self-stimulatory behaviors. List

N/A

Frequently adjusts clothing as if feeling uncomfortable

N/A

Touches everything, can’t keep hand to self

N/A

No apparent response to being touched or bumped

N/A

Avoids busy, unpredictable environments

N/A

Intent on controlling/manipulating to keep environment predictable

N/A

Resistive to grooming activities such as haircuts, nail trims, dentist. List

N/A

Extreme reaction to tickling

N/A

Examines objects by placing in mouth

N/A

Appears under/over sensitive to pain (circle if applicable)

N/A

Avoids crunch, chewy foods

N/A

Socks have to be just right; no wrinkles or twisted seams

N/A

Picky eater. Prefers certain textures. List

N/A

Limits self to particular foods/temperatures. List

N/A

Hands seem to be unfamiliar appendages

N/A

Difficulty identifying which body part touched without vision

N/A

Untidy/messy dresser

N/A

Shoes worn loose or untied, or on wrong feet

N/A

Unable to identify familiar objects via touch only

N/A

Poor awareness of body part relationships

N/A

Rubs or scratches a spot that has been touched

N/A

Hyperactive gag response

N/A

Avoids/seeks going barefoot on textured surfaces (grass, sand)

N/A

D. AUDITORY (LISTENING, LANGUAGE, & SOUND)

Overly sensitive to loud sounds or noises

N/A

Covers ears to shut out auditory input

N/A

Hears sound others don’t hear, or before others notice

N/A

Sensitive to certain voice pitches

N/A

“Tunes out” or ignores sound nearby

N/A

Unable to pay attention when there are other sounds nearby

N/A

Irrational fear of noisy appliances

N/A

Can only work with TV, stereo on

N/A

Hums, sings softly, “self-talks” through a task

N/A

Language hard to understand

N/A

Voice volume too soft or too loud

N/A

Seeks out toys, other objects which make sound. List

N/A

Craves music, other specific sounds

N/A

Needs visual cue to respond to verbal commands or requests

N/A

Needs increased volume to respond

N/A

Mispronounces words (bisghetti, magazine, etc.)

N/A

Doesn’t respond when name is called

N/A

Frequently misunderstands what you say or responds with incomplete understanding

N/A

Doesn’t seem to hear the beginning or middle of statements

N/A

Frequently asks you to repeat what you said

N/A

Slow or delayed response

N/A

Difficulty sequencing the order of events when telling a story/describing an event

N/A

Word finding difficulty (“that thingy”)

N/A

Not precise in word selection

N/A

Limited use of descriptive vocabulary

N/A

Participates little in conversation

N/A

Enjoys strange noises, makes repetitive sounds

N/A

E. OCULAR MOTOR & VISUAL PERCEPTUAL

Poor depth perception, difficulty or hesitancy climbing or descending stairs

N/A

Poor awareness of space in relation to things around self/gets lost easily

N/A

Skips words/lines or loses places when reading

N/A

Letter/number/word reversals

N/A

Overly sensitive to light/sunlight

N/A

Difficulty tracking a moving target

N/A

Poor visual monitoring of hand when writing/manipulating objects

N/A

Appears not to hear what is said

N/A

Poor eye contact

N/A

Dislikes having vision occluded or being in the dark

N/A

Squints, bloodshot eyes, eyes tear, raises eyebrows, rubs eyes

N/A

Fails to notice visual cues from the environment

N/A

Hyper vigilant or visually distracted

N/A

Difficulty with/enjoys puzzles

N/A

Writing illegible/misplaced on lines or page

N/A

Dislikes/likes drawing

N/A

Difficulty finding objects in complex background

N/A

Over stimulated by busy visual environment

N/A

Keeps eyes too close to work

N/A

Tilts head/props head/lays head on arm with deskwork

N/A

Uses peripheral more than central vision

N/A

F. TASTE AND SMELL

Highly sensitive to common odors or to faint odors unnoticed by others

N/A

Does not seem to notice unpleasant smells

N/A

Tends to overly focus on the taste or smell of non-food items

N/A

Will not taste food prior to smelling it and approving of its smell

N/A

Prefers bland foods/highly seasoned foods (circle appropriate)

N/A

Hypersensitive to body odors such as breath or scents of soap, perfume, etc.

N/A

G. SUCK, SWALLOW BREATHE SYNCHRONY (RESPIRATION)

Difficulty using straw

N/A

Poor lip closure on eating, drinking, utensils

N/A

Limited skills with blow toys

N/A

Unable to whistle

N/A

Poor saliva control/drooling

N/A

Tongue thrust

N/A

Chokes easily on liquids and/or solids

N/A

Shallow breathing pattern

N/A

Holds breath when applying effort

N/A

Poor breath support for speech-runs out of breath in mid-sentence

N/A

“Breathy” speech

N/A

Speech volume barely audible

N/A

Puts hands on hips to increase lung capacity

N/A

Mouth breathing

N/A

Lower ribcage flared

N/A

H. FINE MOTOR SKILLS

Difficulty drawing, coloring, cutting

N/A

Lines drawn too lightly, wobbly, too dark, breaks pencil often (circle appropriate)

N/A

Poor handwriting in printing , cursive

N/A

Lack of well established hand dominance

N/A

Difficulty using two hands together

N/A

Prefers to eat with fingers

N/A

Snaps, Zippers, Buttons are difficult/impossible to manage

N/A

Immature grasp of tools such as pencil, fork, spoon, and toothbrush

N/A

Enjoys manipulatives, puzzles, construction toys, coloring, drawing (circle appropriate)

N/A

I. BILATERAL COORDINATION & MOTOR PLANNING

Difficulty crossing body midline with head or arms/legs

N/A

Limited rotation of pelvis and/or shoulder girdle around central core of body

N/A

Poor coordination of both eyes, hands, and/or legs for symmetrical movements

N/A

Difficulty performing two different tasks at the same time (cut meat with knife and fork, hold & turn paper while cutting with scissors)

N/A

Letter and number reversals

N/A

Poor reading speed and/or comprehension

N/A

Ambidexterity/mixed hand dominance

N/A

Difficulty with projected action sequence (catch a ball, bat a ball)

N/A

Difficulty performing a new as opposed to a habitual, motor response strategy

N/A

Difficulty with timing and rhythm of movements

N/A

Disorganized approach to task

N/A

Prefers talking to doing

N/A

Problems in construction and /or manipulation of materials

N/A

Poor articulation

N/A

Unable to conceive, organize and sequence movements requires to complete a task

N/A

Insufficient body awareness

N/A

Inefficient/disorganized with self-help skills

N/A

Poor gross/fine motor control of body when attempting new activities

N/A

Misunderstands meaning of verbal cues when instructed to move or position body

N/A

Difficulty positioning self squarely on furniture, equipment

N/A

Poor visual-motor coordination

N/A

Difficulty imitating motions or playing games such as “Simon Says”

N/A

Fails to adapt body posture to demands of activity

N/A

Extraneous movements relative to demands of task

N/A

I. BILATERAL COORDINATION & MOTOR PLANNING

Oversensitive, under-sensitive, fluctuating sensitivity to stimuli

N/A

Unusually high, low, fluctuating activity level

N/A

Difficulty with transitions or change

N/A

Difficulty modulating behavioral state

N/A

Resistant to help from caregivers to modulate state

N/A

Demonstrates defensive responses to non-noxious and harmless sensory events

N/A

Difficulty attaining or maintaining optimum level of arousal for attending to task at hand

N/A

K. EMOTIONAL/SOCIAL BEHAVIORS

Intense, explosive

N/A

Easily frustrated, anxious

N/A

Can’t sit still, hyperactive

N/A

Clingy, whiny, cries easily

N/A

Stubborn, inflexible, uncooperative

N/A

Poor self-concept/low self-esteem

N/A

Highly sensitive/can’t take criticism

N/A

Feelings of failure/ frustration

N/A

Gives up easily

N/A

Hard to awaken

N/A

“Up and ready to go”

N/A

Hard to get to sleep

N/A

Difficulty making choices

N/A

Restless/deep/light sleeper

N/A

Fearful. List

N/A

Unable to adjust to changes in routine

N/A

Slow to, or unable to make timely transitions

N/A

Prefers company of adults or older children

N/A

Prefers to play with younger children

N/A

Easily discouraged or depressed

N/A

Enjoys team sports

N/A

Poor loser

N/A

Fails to see humor in situations

N/A

Needs more protection from life than peers

N/A

Accident prone

N/A

Difficulty expressing emotions verbally

N/A

Active, outgoing, enthusiastic

N/A

Inefficient way of doing things

N/A

Form OT-Q

Form OT-Q

Form OT-Q: OT / SPD Questionnaire

OT/SPD QUESTIONNAIRE

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