Sensory Learning Program

Daily Questionnaire

If you have any questions, please call us at 520-886-8800.

First and Last Name

What is the current activity level? (hyper / mellow / varies / etc.)

How is the current sleeping situation? (gets to sleep well / poorly; stays asleep well / poorly; etc.)

Are there any current sensory issues? (problems with / better with loud noises, bright lights, touch, etc.)

How are the current motor skills? (clumsy / graceful / varies / etc.)

How are the current speech/language skills? (not understandable / understandable; (not) able to get to the point; etc.)

How are current cognitive or perceptual skills? ( (not) able to understand instructions; (not) able to reason through activities; etc.)

How are current personal/social skills? ( (not) able to get point across; (not) able to understand social situations; etc.)

How are current emotional skills? (calmer / more emotional; less / more outbursts; etc.)

How are current behavioral skills? (getting into more/less trouble; helping or sharing more/less; etc.)

How are current self-care skills? (better/worse hygiene; better/worse clutter in room; etc.)