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  1. Surveys
  2. 2015
  3. October
  4. A
  5. ASD
0%
Exit Survey
 
Please indicate the degree to which each statement is true of the student's response to/need for touch, with 1 being the least true and 5 being the most:
1 2 3 4 5 N/A
1. Like to be touched?
2. Dislike being held or cuddled?
3. Prefer to touch rather than be touched?
4. Seem excessively ticklish?
5. Seem easily irritated or enraged when touched by others?
6. Have a strong need to touch people and objects?
7. Seem to pick fights?
8. Pinch, bite or otherwise hurt self or others?
9. Frequently bump or push others?
10. Bang head on purpose?
1 2 3 4 5 N/A
11. Like to touch animals?
12. Dislike the feeling of certain clothing?
13. Over or under dress for the temperature?
14. Seem overly sensitive to food or water temp?
15. Seem overly sensitive to rough food textures?
16. Prefer tub baths over showers?
17. Like to play in water, sand, mud, clay, etc.?
18. Seem to lack the normal awareness of being touched?
19. Often seem unaware of cuts, bruises, etc.?
20. Avoid using hands?
21. Mouth objects or clothes excessively?
 
 
Please indicate the degree to which each statement is true of the student's movement, with 1 being the least true and 5 being the most:
1 2 3 4 5 N/A
1. Arch back when held or moved?
2. Enjoy being rocked?
3. Like being tossed in the air?
4. Like fast rides?
5. Like to swing?
6. Spin or whirl more than other children?
7. Get carsick easily?
8. Get nauseous and vomit from other kinds of movement?
9. Rock / bounce while sitting?
10. Jump a lot?
11. Have fear in space (stairs, heights)?
12. Lose balance easily?
13. Walk on toes (not whole foot)?
 
 
Please indicate the degree to which each statement is true of the student's vision, with 1 being the least true and 5 being the most:
1 2 3 4 5 N/A
1. Have a visual problem?
2. Seem very sensitive to light?
3. Have trouble using eyes?
4. Avoid eye contact?
5. Distracted by visual?
6. Dislike eyes covered?
7. Able to close eyes for short periods?
8. Make reversals when writing, copying, reading?
9. Like playing in the dark?
10. Have trouble with shapes, colors, size?
11. Squint often?
12. Able to look far away?
13. Able to look close?
 
 
Please indicate the degree to which each statement is true of the student's sense of taste and smell, with 1 being the least true and 5 being the most:
1 2 3 4 5 N/A
1. Act like all food is the same?
2. Explore with taste?
3. Chew on non food items?
4. Have any feeding problems?
5. Trouble changing to textures?
6. Hypersensitive to smells?
7. Taste / smell toys, clothes, or foods more than usual?
 
 
Please indicate the degree to which each statement is true of the student's hearing, with 1 being the least true and 5 being the most:
1 2 3 4 5 N/A
1. Have hearing loss?
2. Have (had) PE tubes?
3. Have (had) a lot of ear infections?
4. Hypersensitive to sounds?
5. Have fear of unexpected noises?
6. Have fear of unusual sounds?
7. Distracted by sound?
8. Miss sounds or words?
9. Have trouble listening?
10. Have trouble locating sound?
1 2 3 4 5 N/A
11. Make loud noises?
12. Sing / dances to music?
13. Have trouble imitating rhythmic sounds?
14. Have trouble understanding or following directions?
15. Unable to follow 2-3 directions?
16. Talk excessively?
17. Talking interferes with listening?
18. Have delayed speech development?
 
 
Please indicate the degree to which each statement is true of the student's muscle tone, with 1 being the least true and 5 being the most:
1 2 3 4 5 N/A
1. Feel heavier than looks?
2. Have good endurance?
3. Have muscle problems?
4. Have flat feet?
5. Slump when sitting?
6. Get tired easily?
7. Seem weak?
8. Keep mouth open?
9. Prefer lying on back?
 
 
Please indicate the degree to which each statement is true of the student's coordination, with 1 being the least true and 5 being the most:
1 2 3 4 5 N/A
1. Sit, stand or walk late?
2. Sit, stand or walk early?
3. Creeping or crawling phase omitted or short?
4. Creeping or crawling phase very long?
5. Movements slow, plodding, deliberate?
6. Play with toys appropriately for age?
7. Have trouble with dressing, buttoning, zipping or shoe tying?
8. Clumsy with toys?
9. Have trouble holding pencil correctly?
10. Creep on tummy or bottom?
1 2 3 4 5 N/A
11. Trip or fall a lot?
12. Seem awkward?
13. Bump into things?
14. Use his/her dominant hand effectively?
15. Have poor handwriting?
16. Handle small things easily?
17. Eat neatly for age?
18. Have rigid movements?
19. Grimace or sue tongue in fine motor task?
20. Shaky?
21. Like sports, PE
 
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