Autism Dental - Autism Sensory Profile Questionnaire
Thank you for choosing Autism Dental Center for Children. The following questions will help get us to know about your child's needs. It is important for you to answer these questions because it will help us better serve your child.
Patient Information
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Child's First Name
Middle Initial
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Child's Last Name
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Child's Birth Date (MM/DD/YYYY)
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Parent or Guardian Full Name:
Evening Phone
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Daytime Phone
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Is this your first visit to our offices?
Yes
No
Please Help Us Understand Your Child's Autism
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What Type of Autism?
High Functioning Autism
Moderate to Severe Autism
PDD-NOS
Aspergers Syndrome
Rett Syndrome
Not yet Determined
Other
If "Other", please explain.
Sensory Profile
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Touch Response (Oral and Facial)
Mostly Resists
Mostly Seeks
Neith Seeks nor Resists
I Don't Know
Touch Response (General)
Mostly Resists
Mostly Seeks
Neith Seeks nor Resists Touch
I Don't Know
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Texture Response (Oral and Facial)
Very Sensitive to Things in Mouth
Likes to Put Everything in Mouth
Seems Normal
I Don't Know
Texture Response (General)
Resists certain Textures
Likes to Touch Everything
Seems Normal
I Don't Know
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Proximity to People
Does not Like being Close to People
Crowds in on People
Seems Normal
I Don't Know
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Proprioceptive Response
Comforted by Large or Heavy Objects
Does not Like Large or Heavy Objects
Neither of the Above
I Don't Know
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Taste Response
Very Selective Taste Preferences
Puts Everything in Mouth
Packs or Pockets Food in the Mouth
Seems Normal
I Don't Know
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Response to Sounds
Very Sensitive to Sounds
Seeks Certain Sounds
Seems Normal
I Don't Know
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Response to Visual Stimuli
Very Sensitive to Light
Seeks Lights, Mirrors
Seems Normal
I Don't Know
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Response to Smells
Very Sensitive to Smells
Seeks Unusual Smells
Seems Normal
I Don't Know
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Response to Change in Position
Very Sensitive to Change in Position
Seeks Changes in Position
Seems Normal
I Don't Know
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Oral Habits Profile
Yes/Likes
No/Dislikes
Normal
Uncertain
Extreme Sensitivity-Easily Vomits
Biting
Chewing
Grinding Teeth
Uses Bottle/Sippy Cup
Wiping Face
Kisses
Utensils
Cups
Straws
Toothbrush
Floss
Appointment Information
Please give any other information that may be helpful
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