Infant Sensory Profile

Child's Name: *

First NameLast Name

Gender:

MaleFemale

Birth Date*

MonthDayYear

Test Date:

Examiner/Service Provider's Name:

First NameLast Name

Completed by/Caregiver's Name: *

First NameLast Name

Caregiver's Relationship to Child: *

Name of Daycare Center:

Was this child born prematurely?

YesNo

If Yes, by how many weeks?

In what order was your child born in relation to siblings (for example, 1st child, 3rd child, etc.)?

Have there been more than three children between the ages of birth through 18 years living in your household during the past 12 months?

YesNo

Instructions

The pages that follow contain statements that describe how babies may act. Please read each phrase and select the option that best describes how often your baby shows these behaviors. Please mark one option for every statement.

Use these guidelines to mark your responses:

When presented with the opportunity, my baby...

Responds in this manner Almost Always (90% or more of the time).

Responds in this manner Frequently (75% of the time).

Responds in the manner Half the time (50% of the time).

Responds in the manner Occasionally (25% of the time).

Responds in this manner Almost Never (10% or less of the time).

If you are unable to answer because you have not observed the behavior or believe that it does not apply to your baby, please check Does Not Apply.

General Processing: My baby...

	Almost Always	Frequently	Half the Time	Occasionally	Almost Never	Does Not Apply
1.) stays quiet and calm in an active setting compared to other babies.
2.) is unaware of people coming in or leaving the room.
3.) needs the same routine to stay content and calm.
4.) acts in a way that interferes with family schedules and plans.
5.) requires help to get to sleep.
6.) is irritable compared to other babies.
7.) sleeps more than other babies.
8.) only pays attention when I touch my baby (and hearing is OK).

General Processing Comments:

Auditory Processing: My baby...

	Almost Always	Frequently	Half the Time	Occasionally	Almost Never	Does Not Apply
9.) enjoys making mouth sounds (for example, blowing raspberries, making noises with lips, humming).
10.) ignores me when I am talking.
11.) becomes upset by sudden everyday sounds.
12.) becomes more animated and engaged around music, talking, or sound toys.

Auditory Processing Comments:

Visual Processing: My baby...

	Almost Always	Frequently	Half the Time	Occasionally	Almost Never	Does Not Apply
13.) misses eye contact with me during everyday interactions
14.) looks away from toys or faces.
15.) looks away or becomes restless in noisy settings or with noisy toys.
16.) blinks a lot when objects or people come close to face.

Visual Processing Comments:

Touch Processing: My baby...

	Almost Always	Frequently	Half the Time	Occasionally	Almost Never	Does Not Apply
17.) becomes upset when having nails trimmed
18.) needs to be swaddled or wrapped to relax
19.) is startled by texture differences (for example, on grass, on carpet, on blankets).

Touch Processing comments:

Movement Processing: My baby...

	Almost Always	Frequently	Half the Time	Occasionally	Almost Never	Does Not Apply
20.) enjoys rhythmical activities (for example, swinging, rocking, car rides).
21.) resists having head tipped back during bathing.
22.) cries or fusses with everyday movement.
23.) needs more head support when being held compared to other babies.

Movement Processing Comments:

Oral Sensory Processing: My baby...

	Almost Always	Frequently	Half the Time	Occasionally	Almost Never	Does Not Apply
24.) struggles to close mouth when feeding from the breast or bottle (for example, doesn't latch on).
25.) enjoys making movements or sounds with mouth.

Oral Sensory Comments: