Name *

First Name

Last Name

Low tolerance to stress; poor adaptability; dislike of change or surprise.

Yes

Anxiety seemingly unrelated to reality, when young lead to screaming, kicking, biting, or running away.

Yes

Hypersensitivity to touch, sound, changes in visual field.

Yes

Fatigue, easily always tired.

Yes

Breath holding/fainting, cried until fainting as a kid.

Yes

Insecure / Lack of trust in oneself fear of social embarrassment, difficulty, uncomfortable or stress when looking people directly in the eye.

Yes

Overly clingy or may be unable to accept or demonstrate affection easily.

Yes

Negativism, defeatist attitude; temper tantrums.

Yes

Won’t try new activities, especially where comparison or excellence is expected.

Yes

Immediate motor freeze or paralysis under stress, can’t think and move at the same time, sometimes terrified feeling like you are going to die.

Yes

Poor posture.

Yes

Toe walker as a kid or as an adult.

Yes

Poor balance and coordination, falling especially when looking up or down.

Yes

Poor eye movement control, poor near vision reading and copying, tendency to be crosseyed.

Yes

Difficulty judging space, distance, depth and speed, visual-perceptual difficulties.

Yes

Problems with spatial concepts in math,reasoning, word and geometry problems.

Yes

Poor concentration, poor short term memory.

Yes

Fatigue while reading or when working or studying at a desk.

Yes

Motion sickness, afraid of heights, ground appears to move.

Yes

Poor development of self identity, shy, tendency to be easily influenced by others.

Yes

Poor handwriting, writes slowly and complains of writers cramp, hates writing.

Yes

Difficulty reading and tracking, inability to follow line, losing place, missing parts of a line when reading.

Yes

Left-right confusion (Mixed laterality), Ambidextrous

Yes

Difficulty copying, judgment of distance may be affected.

Yes

Great discrepancy between verbal and written expression.

Yes

ADHD/OCD characteristics, impatient, impulsive.

Yes

Poor left-right knowledge, reversal of letters and numbers.

Yes

Difficulty catching a ball, bilateral activities or crossing midline.

Yes

Poor at sports, dancing or Bilateral integration, eye hand coordination difficulty.

Yes

In adults there can be chronic shoulder and/or neck problems.

Yes

Hypersensitivity to sudden, noise, light or movement, excessive blinking, dilated pupils.

Yes

A hyper startle response to sound or sudden movements, followed by rapid heartbeat, panic attacks.

Yes

Dislike of change, difficulty with new or stimulating experiences.

Yes

Mood swings, unexpected sudden changes in behavior, aggressive outbursts.

Yes

Vestibular problems (Imbalance, dizziness, motion sickness, vertigo).

Yes

Chronic anxiety, flushing uncontrollably when embarrassed or nervous.

Yes

Frequent ear and throat infections.

Yes

Depleted energy, fatigue, mood swings.

Yes

Chronic digestive problems from childhood, sensitivity to foods or food additives, craves sweets.

Yes

Difficulty focusing on details, sensitive to certain sounds or difficulty shutting out background noise.

Yes

Can’t sit still; fidgety, restlessness, hyperactivity.

Yes

Short term memory problems, poor listening skills.

Yes

Bedwetting beyond age 5, chronic bladder or bowel control issues.

Yes

Sensitive to tight clothing around waist, or tags on clothes, very ticklish on back.

Yes

Constant noise making.

Yes

Attention and concentration problems.

Yes

Difficulty co-ordinating normal walking gait; falling.

Yes

May affect fluency and mobility in physical activities or sports.

Yes

Can contribute to the development of scoliosis (curvature) of the spine.

Yes

Body tends to tilt to one side, can cause chronic back, or neck pain.

Yes

Poor posture (when head bends, the arms will bend causing a tendency to slump when sitting – often will end up almost lying on the desk to write).

Yes

Tend to “hook feet” under desk for support.

Yes

Clumsy.

Yes

Eyes fatigue when reading or focusing near on screen.

Yes

As a child you skipped, missed, or shortened crawling or crawled in unusual way.

Yes

Difficulty sitting with legs crossed ( “W” position when sitting on the floor).

Yes

Poor upper and lower body integration, affecting gross motor skills.

Yes

Poor hand-eye coordination.

Yes

Messy eater.

Yes

Poor organization and planning skills.

Yes

Difficulty or delay learning to walk (beyond 14 months).

Yes

Running awkwardly.

Yes

Poor balance, tripping and falling.

Yes

Can’t press toes in to the ground.

Yes

Problems with sports requiring balance and coordination while running.

Yes

Low back pain while walking and/or standing.

Yes

Shin soreness, complaint that shoes hurt especially over toes.

Yes

Recurrent ankle twisting, flat footed, walk on inside of foot.

Yes

Difficulty walking in the dark (vision is not able to assist balance).

Yes

Frequent heel, calf pain, injury or achillies tendonitis.

Yes

Poor fine motor skills and manual dexterity.

Yes

Inappropriate, immature pencil grip and poor handwriting.

Yes

Weak immune system, poor bladder control, stomach reflux.

Yes

Difficulty processing ideas on to paper.

Yes

Poor posture and/or back pain when working at a desk or computer.

Yes

Constant need to always touch and hold things in hand.

Yes

Difficulty or slow reading.

Yes

Poor memory for details.

Yes

Not good with math or numbers.

Yes

Mixed dominance, ambidexturous or left handed.

Yes

Speech and articulation problems, stuttering.

Yes

Difficulty swallowing and chewing, prefer sucking to chewing, choke often.

Yes

Involuntary tongue or mouth movements when writing or drawing.

Yes

Poor manual dexterity, especially when chewing or speaking.

Yes

Hypersensitivity around lips and mouth, inability to close mouth when chewing.

Yes

Oral fixation, always need to be doing something with mouth, smoking, chewing gum, biting lip, sucking candy, etc.

Yes

Dribbling, and drooling, spitting when speaking.

Yes

Hormonal imbalances or deficiencies.

Yes

Messy eating, dislike of certain texture foods.

Yes

Narrow high arch to palate, poor tooth alignment, orthodontic work.

Yes