Sensory Processing Needs Evaluation Form
Full Name
Date of Birth
Date of Evaluation
Evaluator
Reason for Evaluation
Sensory Areas of Concern (check all that apply)
Auditory
Visual
Tactile
Olfactory
Gustatory
Vestibular
Proprioceptive
Interoceptive
Sensory Behavior Observations
Hypersensitivity (over-responsive)
Hyposensitivity (under-responsive)
Sensory Seeking Behaviors
Impact on Daily Activities
Home
School/Work
Social/Community
Current Strategies/Supports Used
Recommendations/Goals