Form OT-Q

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
MM slash DD slash YYYY

Parent/Guardian (A)


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


Becomes overly excited after movement activity
Thrill seeker on the playground
Avoids movement equipment on playground, prefers to play on
Seeks intense movement; spins, rocks, twirls, bounces, jumps
Shakes head vigorously, assumes upside down position frequently
Uncomfortable on elevators, escalators, motion sickness
Excessive dizziness or nausea from swinging, spinning, riding in car
Preoccupied with movement activities, can’t sit still
Avoids activities which require balance/loses balance easily
Poor negotiation on uneven terrain
As infant, tended to arch back when held or moved
Avoids activities in which feet leave the ground
Fearful of simple challenges to balance
Trips easily, clumsiness
Fear of heights, climbing, fear of falling when no real danger exists
Hesitant when climbing or descending stairs (seeks hand, railing, or walls)
Dislikes being moved
Protests head being tipped backward
Fearful of being tossed in air or turned upside down
Bumps head often: doesn’t extend arms when pushed from behind
Often holds head, neck, and shoulders stiffly
Holds head upright when bending over or leaning (dislikes somersaults)


Difficulty controlling movement, uses too little or too much power/force
Insecure regarding body movement
Poor posture/postural instability
Props head on hand or forearm
Prefers/avoids crunchy or chewy foods
Difficulty changing positions or moving slowly
Avoids/seeks vibratory stimulation (barber’s clippers, electric toothbrush, vibrating toy)
Craves tumbling or wrestling
Frequently gives or requests firm or prolonged hugs
Seeks out adults when on playground
Walks on toes frequently
Drags feet or poor heel-toe pattern when walking
Wide-base stance
Turns whole body to look at person or object
Moves stiffly, head, neck, shoulder rigidity
Plays roughly with people or objects
Bumps into things
Avoids participation in ordinary movement experiences
Resists new physical challenges, saying “I can’t” without attempting
Seems weaker or tires more easily than peers
Appears lethargic
Seeks sedentary play
Leans on objects or people for stability
Weak pencil grasp, little pencil pressure
Cannot lift heavy objects
Moves with quick bursts of activity rather than sustained movement
Achieves standing posture by pushing off floor with hands
Joints extremely flexible
Collapses onto furniture
Avoids “heavy work” activities
Seeks opportunities to fall, crashes into things
Stamps or slaps feet on ground when walking
Kicks heels against floor or chair
Bangs stick or other object along wall or fence when walking
Cracks knuckles
Grinds teeth, bites or chews objects, clothing


Excessive reaction to light touch sensations (anxiety, hostility, aggression) as infant, not calmed by cuddling/stroking
Difficulty standing in line or close to other people
Stands too close to people to the point of irritation
Tenses when patted affectionately
Negative reaction to unseen, unexpected touch
Clothes cover whole body, regardless of weather
Wears minimal clothes, regardless of weather
Avoids certain textures of clothing, materials
Avoids putting hands in messy substances/getting dirty
Engages in self-injurious behaviors. List
Likes to be wrapped tightly in sheet or blanket
Seeks tight spaces
Engages in self-stimulatory behaviors. List
Frequently adjusts clothing as if feeling uncomfortable
Touches everything, can’t keep hand to self
No apparent response to being touched or bumped
Avoids busy, unpredictable environments
Intent on controlling/manipulating to keep environment predictable
Resistive to grooming activities such as haircuts, nail trims, dentist. List
Extreme reaction to tickling
Examines objects by placing in mouth
Appears under/over sensitive to pain (circle if applicable)
Avoids crunch, chewy foods
Socks have to be just right; no wrinkles or twisted seams
Picky eater. Prefers certain textures. List
Limits self to particular foods/temperatures. List
Hands seem to be unfamiliar appendages
Difficulty identifying which body part touched without vision
Untidy/messy dresser
Shoes worn loose or untied, or on wrong feet
Unable to identify familiar objects via touch only
Poor awareness of body part relationships
Rubs or scratches a spot that has been touched
Hyperactive gag response
Avoids/seeks going barefoot on textured surfaces (grass, sand)


Overly sensitive to loud sounds or noises
Covers ears to shut out auditory input
Hears sound others don’t hear, or before others notice
Sensitive to certain voice pitches
“Tunes out” or ignores sound nearby
Unable to pay attention when there are other sounds nearby
Irrational fear of noisy appliances
Can only work with TV, stereo on
Hums, sings softly, “self-talks” through a task
Language hard to understand
Voice volume too soft or too loud
Seeks out toys, other objects which make sound. List
Craves music, other specific sounds
Needs visual cue to respond to verbal commands or requests
Needs increased volume to respond
Mispronounces words (bisghetti, magazine, etc.)
Doesn’t respond when name is called
Frequently misunderstands what you say or responds with incomplete understanding
Doesn’t seem to hear the beginning or middle of statements
Frequently asks you to repeat what you said
Slow or delayed response
Difficulty sequencing the order of events when telling a story/describing an event
Word finding difficulty (“that thingy”)
Not precise in word selection
Limited use of descriptive vocabulary
Participates little in conversation
Enjoys strange noises, makes repetitive sounds


Poor depth perception, difficulty or hesitancy climbing or descending stairs
Poor awareness of space in relation to things around self/gets lost easily
Skips words/lines or loses places when reading
Letter/number/word reversals
Overly sensitive to light/sunlight
Difficulty tracking a moving target
Poor visual monitoring of hand when writing/manipulating objects
Appears not to hear what is said
Poor eye contact
Dislikes having vision occluded or being in the dark
Squints, bloodshot eyes, eyes tear, raises eyebrows, rubs eyes
Fails to notice visual cues from the environment
Hyper vigilant or visually distracted
Difficulty with/enjoys puzzles
Writing illegible/misplaced on lines or page
Dislikes/likes drawing
Difficulty finding objects in complex background
Over stimulated by busy visual environment
Keeps eyes too close to work
Tilts head/props head/lays head on arm with deskwork
Uses peripheral more than central vision


Highly sensitive to common odors or to faint odors unnoticed by others
Does not seem to notice unpleasant smells
Tends to overly focus on the taste or smell of non-food items
Will not taste food prior to smelling it and approving of its smell
Prefers bland foods/highly seasoned foods (circle appropriate)
Hypersensitive to body odors such as breath or scents of soap, perfume, etc.


Difficulty using straw
Poor lip closure on eating, drinking, utensils
Limited skills with blow toys
Unable to whistle
Poor saliva control/drooling
Tongue thrust
Chokes easily on liquids and/or solids
Shallow breathing pattern
Holds breath when applying effort
Poor breath support for speech-runs out of breath in mid-sentence
“Breathy” speech
Speech volume barely audible
Puts hands on hips to increase lung capacity
Mouth breathing
Lower ribcage flared


Difficulty drawing, coloring, cutting
Lines drawn too lightly, wobbly, too dark, breaks pencil often (circle appropriate)
Poor handwriting in printing , cursive
Lack of well established hand dominance
Difficulty using two hands together
Prefers to eat with fingers
Snaps, Zippers, Buttons are difficult/impossible to manage
Immature grasp of tools such as pencil, fork, spoon, and toothbrush
Enjoys manipulatives, puzzles, construction toys, coloring, drawing (circle appropriate)


Difficulty crossing body midline with head or arms/legs
Limited rotation of pelvis and/or shoulder girdle around central core of body
Poor coordination of both eyes, hands, and/or legs for symmetrical movements
Difficulty performing two different tasks at the same time (cut meat with knife and fork, hold & turn paper while cutting with scissors)
Letter and number reversals
Poor reading speed and/or comprehension
Ambidexterity/mixed hand dominance
Difficulty with projected action sequence (catch a ball, bat a ball)
Difficulty performing a new as opposed to a habitual, motor response strategy
Difficulty with timing and rhythm of movements
Disorganized approach to task
Prefers talking to doing
Problems in construction and /or manipulation of materials
Poor articulation
Unable to conceive, organize and sequence movements requires to complete a task
Insufficient body awareness
Inefficient/disorganized with self-help skills
Poor gross/fine motor control of body when attempting new activities
Misunderstands meaning of verbal cues when instructed to move or position body
Difficulty positioning self squarely on furniture, equipment
Poor visual-motor coordination
Difficulty imitating motions or playing games such as “Simon Says”
Fails to adapt body posture to demands of activity
Extraneous movements relative to demands of task


Oversensitive, under-sensitive, fluctuating sensitivity to stimuli
Unusually high, low, fluctuating activity level
Difficulty with transitions or change
Difficulty modulating behavioral state
Resistant to help from caregivers to modulate state
Demonstrates defensive responses to non-noxious and harmless sensory events
Difficulty attaining or maintaining optimum level of arousal for attending to task at hand


Intense, explosive
Easily frustrated, anxious
Can’t sit still, hyperactive
Clingy, whiny, cries easily
Stubborn, inflexible, uncooperative
Poor self-concept/low self-esteem
Highly sensitive/can’t take criticism
Feelings of failure/ frustration
Gives up easily
Hard to awaken
“Up and ready to go”
Hard to get to sleep
Difficulty making choices
Restless/deep/light sleeper
Fearful. List
Unable to adjust to changes in routine
Slow to, or unable to make timely transitions
Prefers company of adults or older children
Prefers to play with younger children
Easily discouraged or depressed
Enjoys team sports
Poor loser
Fails to see humor in situations
Needs more protection from life than peers
Accident prone
Difficulty expressing emotions verbally
Active, outgoing, enthusiastic
Inefficient way of doing things