Sensory Assessment Checklist Form
Use this checklist to record observations about sensory preferences, sensitivities, and responses.
Person's Name
*
First Name
Last Name
Observation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sensory Responses Matrix
*
Rows
Avoids
Neutral
Seeks
Auditory (sound, noise)
1
2
3
Visual (light, color, movement)
4
5
6
Tactile (touch, textures)
7
8
9
Taste/Smell (flavors, scents)
10
11
12
Movement (balance, motion)
13
14
15
How sensitive is the person to sensory input overall?
*
Not at all sensitive
1
2
3
4
Very sensitive
5
1 is Not at all sensitive, 5 is Very sensitive
Does the person display any strong preferences for specific sensory experiences?
Yes
No
Not sure
Which environments seem to support the person's sensory needs best?
Quiet spaces
Bright, stimulating areas
Outdoor environments
Spaces with movement opportunities
Other
Overall, how comfortable does the person appear in their current environment?
1
2
3
4
5
Additional Comments or Observations
Submit Checklist
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