Navigating My Sensory World: Understanding How I Process Information

Basic Information

Age:

Date:

Daily Life Satisfaction

Are there aspects of daily life that are not satisfying to you?

No Yes

Instructions

Please check the box that best describes the frequency with which you experience the following behaviors:

1 - Almost Never: About 5% or less of the time
2 - Seldom: About 25% of the time
3 - Occasionally: About 50% of the time
4 - Frequently: About 75% of the time
5 - Almost Always: About 95% or more of the time

Taste/Smell Processing

1. I leave or move to another section when I smell a strong odor in a store (e.g., bath products, candles, perfumes).

Almost Never Seldom Occasionally Frequently Almost Always

2. I add spice to my food.

Almost Never Seldom Occasionally Frequently Almost Always

3. I don't smell things that other people say they smell.

Almost Never Seldom Occasionally Frequently Almost Always

4. I enjoy being close to people who wear perfume or cologne.

Almost Never Seldom Occasionally Frequently Almost Always

5. I only eat familiar foods.

Almost Never Seldom Occasionally Frequently Almost Always

6. Many foods taste bland to me (in other words, food tastes plain or does not have a lot of flavor).

Almost Never Seldom Occasionally Frequently Almost Always

7. I don't like strong tasting mints or candies (for example, hot/cinnamon or sour candy).

Almost Never Seldom Occasionally Frequently Almost Always

8. I go over to smell fresh flowers when I see them.

Almost Never Seldom Occasionally Frequently Almost Always

Movement Processing

9. I'm afraid of heights.

Almost Never Seldom Occasionally Frequently Almost Always

10. I enjoy how it feels to move about (for example, dancing, running).

Almost Never Seldom Occasionally Frequently Almost Always

11. I avoid elevators and/or escalators because I dislike the movement.

Almost Never Seldom Occasionally Frequently Almost Always

12. I dislike the movement of riding in a car.

Almost Never Seldom Occasionally Frequently Almost Always

13. I choose to engage in physical activities.

Almost Never Seldom Occasionally Frequently Almost Always

14. I am unsure of footing when walking on stairs (for example, I trip, lose balance, and/or need to hold the rail).

Almost Never Seldom Occasionally Frequently Almost Always

15. I trip or bump into things.

Almost Never Seldom Occasionally Frequently Almost Always

16. I become dizzy easily (for example, after bending over, getting up too fast).

Almost Never Seldom Occasionally Frequently Almost Always

Visual Processing

17. I like to go to places that have bright lights and that are colorful.

Almost Never Seldom Occasionally Frequently Almost Always

18. I keep the shades down during the day when I am at home.

Almost Never Seldom Occasionally Frequently Almost Always

19. I like to wear colorful clothing.

Almost Never Seldom Occasionally Frequently Almost Always

20. I become frustrated when trying to find something in a crowded drawer or messy room.

Almost Never Seldom Occasionally Frequently Almost Always

21. I miss the street, building, or room signs when trying to go somewhere new.

Almost Never Seldom Occasionally Frequently Almost Always

22. I am bothered by unsteady or fast-moving visual images in movies or TV.

Almost Never Seldom Occasionally Frequently Almost Always

23. I don’t notice when people come into the room.

Almost Never Seldom Occasionally Frequently Almost Always

24. I choose to shop in smaller stores because I'm overwhelmed in large stores.

Almost Never Seldom Occasionally Frequently Almost Always

25. I become bothered when I see lots of movement around me (for example, at a busy mall, parade, carnival).

Almost Never Seldom Occasionally Frequently Almost Always

26. I limit distractions when I am working (for example, I close the door or turn off the TV).

Almost Never Seldom Occasionally Frequently Almost Always

Touch Processing

27. I dislike having my back rubbed.

Almost Never Seldom Occasionally Frequently Almost Always

28. I like how it feels to get my hair cut.

Almost Never Seldom Occasionally Frequently Almost Always

29. I avoid or wear gloves during activities that will make my hands messy.

Almost Never Seldom Occasionally Frequently Almost Always

30. I touch others when I’m talking (for example, I put my hand on their shoulder or shake their hand).

Almost Never Seldom Occasionally Frequently Almost Always

31. I am bothered by the feeling in my mouth when I wake up in the morning.

Almost Never Seldom Occasionally Frequently Almost Always

32. I like to go barefoot.

Almost Never Seldom Occasionally Frequently Almost Always

33. I’m uncomfortable wearing certain fabrics (for example, wool, silk, corduroy, tags in clothing).

Almost Never Seldom Occasionally Frequently Almost Always

34. I don’t like particular food textures (for example, peaches with skin, applesauce, cottage cheese, chunky peanut butter).

Almost Never Seldom Occasionally Frequently Almost Always

35. I move away when others get too close to me.

Almost Never Seldom Occasionally Frequently Almost Always

36. I don’t seem to notice when my face or hands are dirty.

Almost Never Seldom Occasionally Frequently Almost Always

37. I get scrapes or bruises but don’t remember how I got them.

Almost Never Seldom Occasionally Frequently Almost Always

38. I avoid standing in lines or standing close to other people because I don’t like to get too close to others.

Almost Never Seldom Occasionally Frequently Almost Always

39. I don’t seem to notice when someone touches my arm or back.

Almost Never Seldom Occasionally Frequently Almost Always

Activity Level

40. I work on two or more tasks at the same time.

Almost Never Seldom Occasionally Frequently Almost Always

41. It takes me more time than other people to wake up in the morning.

Almost Never Seldom Occasionally Frequently Almost Always

42. I do things on the spur of the moment (in other words, I do things without making a plan ahead of time).

Almost Never Seldom Occasionally Frequently Almost Always

43. I find time to get away from my busy life and spend time by myself.

Almost Never Seldom Occasionally Frequently Almost Always

44. I seem slower than others when trying to follow an activity or task.

Almost Never Seldom Occasionally Frequently Almost Always

45. I don’t get jokes as quickly as others.

Almost Never Seldom Occasionally Frequently Almost Always

46. I stay away from crowds.

Almost Never Seldom Occasionally Frequently Almost Always

47. I find activities to perform in front of others (for example, music, sports, acting, public speaking, and answering questions in class).

Almost Never Seldom Occasionally Frequently Almost Always

48. I find it hard to concentrate for the whole time when sitting in a long class or a meeting.

Almost Never Seldom Occasionally Frequently Almost Always

49. I avoid situations where unexpected things might happen (for example, going to unfamiliar places or being around people I don’t know).

Almost Never Seldom Occasionally Frequently Almost Always

Auditory Processing

50. I hum, whistle, sing, or make other noises.

Almost Never Seldom Occasionally Frequently Almost Always

51. I startle easily at unexpected or loud noises (for example, vacuum cleaner, dog barking, telephone ringing).

Almost Never Seldom Occasionally Frequently Almost Always

52. I have trouble following what people are saying when they talk fast or about unfamiliar topics.

Almost Never Seldom Occasionally Frequently Almost Always

53. I leave the room when others are watching TV, or I ask them to turn it down.

Almost Never Seldom Occasionally Frequently Almost Always

54. I am distracted if there is a lot of noise around.

Almost Never Seldom Occasionally Frequently Almost Always

55. I don’t notice when my name is called.

Almost Never Seldom Occasionally Frequently Almost Always

56. I use strategies to drown out sound (for example, close the door, cover my ears, wear ear plugs).

Almost Never Seldom Occasionally Frequently Almost Always

57. I stay away from noisy settings.

Almost Never Seldom Occasionally Frequently Almost Always

58. I like to attend events with a lot of music.

Almost Never Seldom Occasionally Frequently Almost Always

59. I have to ask people to repeat things.

Almost Never Seldom Occasionally Frequently Almost Always

60. I find it difficult to work with background noise (for example, fan, radio).

Almost Never Seldom Occasionally Frequently Almost Always