Short Sensory Profile

Please check the box that best describes the frequency with which your child does the following behaviours. Please answer all of the statements. If you are unable to comment because you have not observed the behaviour or believe that it does not apply to your child, please tick DOES NOT APPLY box.

ALWAYS

When presented with the opportunity, your child always responds in this manner, 100% of the time.

FREQUENTLY

When presented with the opportunity, your child frequently responds in this manner, about 75% of the time.

OCCASIONALLY

When presented with the opportunity, your child occasionally responds in this manner, about 50% of the time.

SELDOM

When presented with the opportunity, your child seldom responds in this manner, about 25% of the time.

NEVER

When presented with the opportunity, your child never responds in this manner, 0%of the time.

34. Responds negatively to unexpected or loud noises (for example, cries or hides at noise from vacuum cleaner, dog barking, hair dryer)

ALWAYS

FREQUENTLY

OCCASIONALLY

SELDOM

NEVER

DOES NOT APPLY

Please upload any medical evidence you have. The following evidence would be helpful:
(accepted formats are pdf, jpg, png and tiff. Max. file size 5MB)

Mothers Details

*Name

*Phone Number

*Email

*Date of Birth (MM/DD/YYYY)

*Occupation

*Nationality

Fathers Details

*Name

*Phone Number

*Email

*Date of Birth (MM/DD/YYYY)

*Occupation

*Nationality

*I confirm that I have read and understood the Patient Information brochure attached, and that I have had ample opportunity to ask questions all of which have been satisfactorily answered.

Yes

*I understand that my (my child) participation in this treatment is entirely voluntary and that I may withdraw at any time, without giving reason, and without this decision affecting my future treatment or medical care.

Yes

*While I (my child) is a subject of this study, I agree to follow the instructions of the doctor/researcher and to call the doctor/researcher immediately if I (my child) become(s) ill or experience(s) any side effects.

Yes

*I give my informed consent for the doctor/researcher to have access to my medical notes in the National Rehabilitation Hospital. I understand that the contents of my medical notes will not be disclosed to a third party.

Yes

*FUTURE USE OF ANONYMOUS DATA: I agree that I will not restrict the use to which the results of this study may be put. I give my approval that unidentifiable data concerning my person may be stored or electronically processed for the purpose of scientific research and may be used in related or other studies in the future.

Yes

I have received, read and understood the Patient Information Brochure for the above study. The participant named above expressed a written willingness to participate in this treatment and I hereby give my consent for this participation:

Instructions

ALWAYS

FREQUENTLY

OCCASIONALLY

SELDOM

NEVER

Tactile Sensivity

Taste/Smell Sensitivity

Movement Sensitivity

Underresponsive / Seeks Sensation

Auditory Filtering

Low Energy/ Weak

Visual / Auditory Sensivity

Gilliam Autism Rating Scale (GARS-2)

Stereotyped Behaviors

Communication

Social interactions

Upload All Medical Reports

Parents Contact Details

Mothers Details

Fathers Details

PARENTS CONSENT FORM

Protocol Title:

Please tick the appropriate answer.

If the participant is under 18 years of age the consent of the parent or guardian must also be obtained.

I have received, read and understood the Patient Information Brochure for the above study. The participant named above expressed a written willingness to participate in this treatment and I hereby give my consent for this participation:

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