Observation-Based Questionnaire

 

ARURA PAEDIATRIC THERAPY SERVICES                              Part 1: Observation-Based Questionnaire

This section focuses on what the therapist directly observes during the child’s therapy session.

Domain	Observation Checklist	Response
Proprioception	Does the child avoid physical activities or seem uncoordinated?	Yes / No
	Does the child frequently bump into objects or people?	Yes / No
Tactile	Does the child avoid messy play like sand or finger painting?	Yes / No
	Does the child show excessive tactile-seeking behaviors (e.g., touching everything)?	Yes / No
Auditory	Does the child cover their ears or get upset in loud environments?	Yes / No
	Does the child appear unaware of loud sounds or voices?	Yes / No
Visual	Does the child avoid bright lights or visually busy environments?	Yes / No
	Does the child seek out bright or fast-moving objects?	Yes / No
Vestibular	Does the child avoid or show fear of movement activities like swinging or spinning?	Yes / No
	Does the child seek excessive movement (e.g., spinning, jumping)?	Yes / No
Oral	Does the child avoid certain food textures or gag easily?	Yes / No
	Does the child chew on non-food items frequently?	Yes / No

Part 2: Parent Interview-Based Questionnaire

This section gathers information based on the parents' observations at home and in everyday settings.

Domain	Parent Interview Questions	Response
Proprioception	Does your child frequently fall, bump into things, or seem clumsy?	Yes / No
	Does your child avoid rough play or activities that require strength?	Yes / No
Tactile	Does your child complain about clothing textures (e.g., tags, seams)?	Yes / No
	Does your child avoid or dislike messy activities like painting or playing with sand?	Yes / No
Auditory	Does your child get distressed by loud noises like vacuum cleaners or crowds?	Yes / No
	Does your child seem unaware when there are loud noises or when you call their name?	Yes / No
Visual	Does your child avoid bright lights or visually stimulating environments (e.g., stores, playgrounds)?	Yes / No
	Does your child focus on bright lights or fast-moving objects more than usual?	Yes / No
Vestibular	Does your child dislike car rides, swings, or other motion-based activities?	Yes / No
	Does your child constantly seek out spinning, jumping, or running?	Yes / No
Oral	Does your child avoid certain food textures (e.g., crunchy, soft)?	Yes / No
	Does your child frequently chew on toys or non-food items?	Yes / No

Part 3: Direct Assessment-Based Questionnaire

This section involves the therapist directly testing sensory responses using specific activities and recording the child's reactions.

Domain	Direct Assessment Activity	Response
Proprioception	Ask the child to carry a small weighted object. Does the child appear uncomfortable?	Yes / No
	Engage the child in a resistive activity (e.g., tug-of-war). Do they seem to enjoy it?	Yes / No
Tactile	Present different textures (e.g., soft, rough, sticky) to the child. Do they avoid certain textures?	Yes / No
	Offer a tactile play activity like finger painting. Does the child show interest or discomfort?	Yes / No
Auditory	Play soft and loud sounds (e.g., a bell or vacuum). Does the child react negatively to any sounds?	Yes / No
	Clap or make noise behind the child. Do they react?	Yes / No
Visual	Present bright and busy visual stimuli (e.g., a toy with flashing lights). Does the child become distressed?	Yes / No
	Test visual tracking with a flashlight. Does the child follow the light easily?	Yes / No
Vestibular	Engage the child in slow swinging or spinning. Does the child show fear or seek more movement?	Yes / No
	Test the child’s tolerance to spinning or jumping activities. Do they enjoy it or seem overwhelmed?	Yes / No
Oral	Present different textured foods (e.g., crunchy, chewy). Does the child avoid or favor certain foods?	Yes / No
	Ask the child to chew on resistive foods (e.g., gum). Does the child seem engaged or disinterested?	Yes / No