Perceptual development assessment form
No.: _ _ _ _
Child's name: gender: date of birth:
Name of parents: work unit:
Tel: Home Address:
Children's physical development is closely related to learning and emotions. To improve children's learning ability and keep them in a good mood, we must first understand their physical development, so we have designed the following questionnaire, please fill it out according to your usual observation of children.
Not often.
(1) Bilateral vestibular brain differentiation is common.
Children especially like to be picked up, shaken and rotated. ? □□□□□
Children seem to be healthy and smart, but when reading cards, picture books and reading, they will reject and not cooperate. □□□□□
Repeatedly bumping into tables, chairs, cups, etc. when the eyes can see, the sense of direction and distance is poor. □□□□□
Dancing, eating, writing and playing drums with poor coordination of hands or feet often forget each other. □□□□□
Looks left-handed, uses both hands, or has not fixed which hand to use. □□□□□
The big move is clumsy, easy to fall, and it doesn't need to be supported by hands, so it looks heavy when pulling. □□□□□
Language expression is not clear enough to combine sentences or stories. □□□□□
Eyes get tired when reading cards and picture books, but you can watch TV and computer for a long time. □□□□□
Don't lift your head, neck, chest, hands and feet off the ground (such as an airplane) when you lie prone on the floor bed. □□□□□
10. I like listening to stories, but I don't like reading cards, picture books and books. Listening is easy to remember, reading is easy to forget.
(2) It is difficult to inhibit the brain physiology:
1 1. Like a person, silent, few friends. I don't like going out to play, so I can find something to do at home. □□□□□
12. Absent-minded, inattentive, with many small moves, I like to look around in class. □□□□□
13. Partial or picky eaters: Do not eat fruits, soft-skinned foods, meat and eggs, but only rice and milk. □□□□□
14. shy. When I meet strangers, I will quickly avoid or nervously twist my skirt, frown and stammer. □□□□□
15. When watching TV or movies, you are easily excited, screaming and jumping for joy, and afraid of watching horror movies. □□□□□
16. Seriously afraid of the dark, need company in the dark, refuse to go out at night, and don't like to go to empty houses. □□□□□
17. I can't sleep when I change my bed, I can't sleep well when I change my pillow or quilt, and I always worry about sleeping space when I go out. □□□□□
18. When someone cleans his nose and ears with a cotton swab, he often feels uncomfortable. □□□□□
19. I like cuddling or hugging with my relatives, like a spoiled or spoiled child. □□□□□
20. Always touch the quilt, hold the quilt, hold clothes or hold toys when sleeping, otherwise you will feel uneasy or sleep badly. □□□□□
(3) Too much tactile defense and insufficient response;
2 1. He has a bad temper, is particularly violent to his relatives, often loses his temper for trivial matters without any reason, and will argue irrationally when things happen. □□□□□
22. Soon after arriving in a new place or a crowded place, ask to leave or run away by yourself. □□□□□
23. After a minor illness or because of trivial matters, I repeatedly told people that I didn't want to go to the early education center, kindergarten, school, and I was afraid to go.
24. I often lick my fingers or bite my nails, and I don't like others to cut my nails. □□□□□
25. I don't like being touched or washing his face. Shampoo or haircut is the most painful thing. □□□□□
26. When an adult pulls his cuffs and socks, or helps him dress and touches his skin, it will arouse his disgust. □□□□□
27. When playing games or toys, I am worried that others will approach from behind, causing distress. □□□□□
28. Feel around, but avoid touching the surfaces of blankets and knitting toys. □□□□□
29. I often like to wear loose long-sleeved clothes, and I often like to wear sweaters or coats when it is not cold. □□□□□
30. I love chatting or non-contact communication, but I am very reluctant to touch my friends' shoulders or skin. □□□□□
3 1. I am very sensitive to some fabrics, and I don't like clothes made of that fabric. □□□□□
32. I am sensitive to my own affairs and easily emotional. I can't tolerate changes in plans or results. □□□□□
33. I always feel very painful and complain about insignificant bruises, small lumps and small knife wounds. □□□□□
34. Stubborn, paranoid and uncooperative, he always insists on doing things in his own way and has no flexibility in things. □□□□□
(4) Use developmental disorder: children under three years old (excluding the whole three years old) do not need this item.
35. At the age of three or four, I can't wash my hands or wipe my ass when I go to the toilet. □□□□□
36. Three or four years old, I still can't use chopsticks, or I have been eating with a spoon and can't hold a pen. □□□□□
37. Four or five years old can't play with big toys such as riding, climbing down and drilling. □□□□□
38. At the age of five or six, I can't stand up and swing with my feet, climb rope nets and climb bamboo poles. □□□□□
39. Putting on and taking off socks, clothes, buttons and shoelaces has always been slow or impossible. □□□□□
40. I can't take a shower by myself when I go to primary school, and I can't jump rope with one foot. □□□□□
4 1. After primary school, I was not good at writing with a pen, cutting and pasting homework, coloring, etc. Or very slow. □□□□□
42. When eating, rice grains or vegetables are often scattered all over the floor, which makes it difficult to clean up desks, schoolbags and toys. □□□□□
43. It is awkward to do manual work and housework, and it is also difficult to grasp when using tools. □□□□□
44. In daily life and games, actions are slow, inactive and inefficient. □□□□□
45. Parents often knock over dishes and spill milk, which needs special protection. □□□□□
(5) Visual space and sense of form:
46. When playing games such as building blocks, puzzles and plastic splicing, the action is very slow. □□□□□
47. When you are away from home, it is often impossible and difficult to reach your destination, and it is easy to get lost. □□□□□
48. When coloring with crayons and writing with pencils, the movements of hands are inflexible, often exceeding the outline and squares. □□□□□
49. Finding similar and different games is very slow, and it is difficult to distinguish the similarities and differences of patterns. □□□□□
50. Poor visual focus, such as playing maze, snake, Tetris and other games, can not be successfully completed. □□□□□
(6) proprioception (gravity insecurity):
5 1. Walking, running and jumping often bump into things, and they are not good at pitching and passing with their peers, so it is difficult to queue up to play games. □□□□□
52. Be extra careful and hesitant when crossing the road, even if it is not high, you dare not walk around with your head down. □□□□□
When he was picked up and held high, he showed anxiety and was anxious to land. □□□□□
I dare not jump from high to low. I felt very nervous when I fell from a height. □□□□□
55. I don't like to do somersaults, rolling and other game activities with my head and feet upside down. □□□□□
56. If you don't like the ferris wheel, roller coaster and other mobile amusement facilities, you will feel scared and uneasy. □□□□□
57. Walking on the uneven ground, getting on and off, and walking in the carriage all show slow movements. □□□□□
58. When going up and down stairs and climbing, hold the railing tightly for fear of falling down. □□□□□
59. When rotating, it is easy to lose balance; When the car is driving, turning too fast will also scare yourself. □□□□□
60. I don't like walking in the highlands. I always complain and feel nervous. □□□□□
(7) Emotional response to life pressure: People under five years old (excluding five years old) do not need this item.
6 1. Declining grades, being in a trance, easily distracted by reading, and abnormal mood and behavior. □□□□□
62. Bad temper, poor self-control, and serious fighting and swearing. □□□□□
63. The demands on teachers and parents are often unbearable; Can not adapt to the environment, easy to feel frustrated. □□□□□
64. I don't feel good about my image, I'm not confident enough, I feel bad, and my emotional behavior is abnormal. □□□□□
Please answer the following questions, fill in the statistical scores in the table below and send them to xiaojing 1970@sina.com by e-mail. We will contact you as soon as possible and inform you of the evaluation results.
The child is a boy, 4 years old, born by caesarean section because his leg is wrapped in umbilical cord.
Children's learning and emotional difficulties and problems;
1, carsick, afraid to ride the carousel and swing (grandma and dad were born carsick);
2, kindergarten teachers reflect active, inattention in class, inattention, love to make small moves, like playing tricks on people;
3, speaking late, the language expression is not very smooth, and I don't take the initiative to talk about kindergarten when I go home;
4. Thank you.
Sensory integration examination result table
Evaluation and description of starting and ending questions and scores of various comprehensive conditions for sensory integration development
1. vestibular balance and bilateral brain differentiation 01-124
2. Neurophysiological inhibition difficulty 12—2027
3. Tactile defense ability 2 1-3428
4. Developmental disorder (over 3 years old) 35-45 19
5. Perception of visual space and form 46-50 8
6. Serious insecurity 5 1-60 22
7. Self-control ability, emotional development (over 5 years old) 6 1-62-
8. Frustration tolerance, self-confidence (over 5 years old) 63-64-
9. Comprehensive capacity 01-64128