Student's Name *

First Name

Last Name

Parent's Name (If applicable) *

First Name

Last Name

Phone *

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Date *

MM

DD

YYYY

--- MORO REFLEX ---

The Moro reflex, present at birth, is a survival mechanism triggered by a real or perceived threat. It is closely linked to all of our sensory systems. When retained, this reflex can have a significant impact on a child's behavior and development. Select those that apply.

• Avoidance of eye contact or prolonged staring without blinking

Yes

• Reduced attention span and increased distractibility

Yes

• Difficulty with activities requiring balance or coordination (e.g., riding a bike, skateboarding, skating)

Yes

• Gravitational insecurities, including an excessive fear of falling or heights

Yes

• Motion sickness

Yes

• Discomfort with changes in routine, difficulty adapting to new situations or surprises

Yes

• Challenges in accepting or expressing affection

Yes

• Easily startled or fearful in unfamiliar situations. May be impulsive or aggressive.

Yes

• Persistent anxiety or frequent panic attacks

Yes

• Sleep disturbances, such as difficulty falling or staying asleep

Yes

• Hypersensitivity to sensory stimuli, including touch, sound, light, texture, smell, food, and sudden movements

Yes

• A tendency to remain in a heightened state of "fight or flight" during waking hours

Yes

• Behavioral and emotional regulation difficulties or immaturity

Yes

• Weakened immune system, with symptoms such as allergies, adrenal fatigue, and food sensitivities

Yes

• Muscle tension – body feels “on guard”

Yes

• Need to control games or outcomes (e.g. Rigidity, manipulates situations to have a certain outcome, might be insecure)

Yes

• Difficulty calming down, becomes easily distressed (e.g. Emotional outbursts, needs extra time to feel safe and calm)

Yes

• May have hypersensitivity if the feet leave the ground or the head is titled backwards (e.g. avoids swings, somersaults, during bath to wash hair or even trying to lay on the back)

Yes

--- ATNR REFLEX ---

The ATNR plays a critical role in the development of the visual system, which is essential for tasks such as reading and writing. This reflex also contributes to eye-hand coordination and the ability to cross the midline of the body. Select those that apply.

• Difficulty with rolling or crawling

Yes

• Lack of balance, instability, and coordination

Yes

• Struggles with tasks that require crossing the midline (e.g., using the right hand to cross to the left side of the body and vice versa) and difficulty coordinating both hands in unison

Yes

• Difficulty following multiple-step instructions

Yes

• Challenges with sports and physical activities, often resulting in frustration

Yes

• Appears clumsy, with frequent dropping of objects

Yes

• No clear hand dominance (appears ambidextrous)

Yes

• Robotic or stiff movements when walking or crawling (e.g., arm and leg move together)

Yes

• Challenges with eye-hand coordination

Yes

• Poor speech production

Yes

• Difficulty with binocular vision

Yes

• Struggles with academic tasks such as spelling, reading, math, and handwriting

Yes

• Poor visual-motor skills (e.g., difficulties with handwriting, dressing, and eating)

Yes

• Difficulty copying from paper or the board

Yes

• Loses place when reading from left to right

Yes

• May have an awkward gait or appear clumsy

Yes

• Difficulty thinking and writing simultaneously, resulting in immature handwriting

Yes

• Symptoms of dysgraphia

Yes

• Letter and number reversals

Yes

• Difficulty with visual tracking and trouble writing across the page

Yes

• May have had a preference for walking on toes as a young child

Yes

--- STNR REFLEX ---

The STNR involves both extension and flexion movements and is essential for a child to learn how to crawl, transition from a sitting to standing position, and for the development of their visual system. When retained, this reflex can interfere with a variety of developmental milestones. Select those that apply.

• Struggles with math

Yes

• Poor posture, often slumping when sitting or standing

Yes

• Lack of balance and coordination, resulting in clumsiness

Yes

• Messy eating habits

Yes

• Tendency to lay on the desk at school

Yes

• Use of W-sitting position

Yes

• Difficulty swimming

Yes

• May sit on legs while seated or wrap legs around the chair

Yes

• Crawled using a "bear walk" pattern or skipped crawling altogether

Yes

• Difficulty with eye tracking for reading or catching a ball; struggles to adjust vision from near to far (e.g., transitioning from the board to paper)

Yes

• Poor binocular vision and eye-hand coordination

Yes

• Poor depth perception, resulting in struggles to catch a ball

Yes

• Difficulty with binaural hearing (hearing with both ears)

Yes

• Poor awareness of space and time

Yes

• Difficulty aligning numbers in math homework

Yes

• Possible pelvic rotation

Yes

• Difficulty reading while sitting up with elbows and legs bent; often prefers to lay on the floor with elbows bent and legs out

Yes

• Arms may move similarly or hang down from the sides while walking or running, resembling an ape-like movement with slumped arms or bent knees

Yes

• Difficulty copying from a board, losing place, skipping lines

Yes

• Possible farsightedness

Yes

• Difficulty tuning out background noise

Yes

• Slower when copying or writing, especially when looking up and down *

Yes

• Poor standing posture, with slouching or chin jutting out *

Yes

• Difficulty with daily tasks such as dressing, brushing teeth, and tying shoes *

Yes

• Struggles with activities involving hand-eye coordination, such as catching, throwing, kicking, and hitting a ball *

Yes

• Difficulty moving the upper and lower body independently of each other *

Yes

• Challenges in swimming over water *

Yes

• Difficulty recognizing social cues *

Yes

• Poor speech and language skills *

Yes

• Difficulty with vertical tracking (e.g., following text from top to bottom) *

Yes

• Difficulty with skipping, jumping, and balancing activities (e.g., hopscotch, jump rope) *

Yes

• Difficulty following multi-step movement instructions *

Yes

--- TLR REFLEX ---

The Tonic Labyrinthine Reflex (TLR) plays a significant role in developing a child’s muscle responses, which are essential for proper head alignment, balance, coordination, visual tracking, auditory processing, and muscle development. This reflex is integral to the overall development of motor skills and sensory processing. Select those that apply.

• Dislikes physical activity due to poor coordination

Yes

• Struggles with balance, especially when looking up or down; difficulty walking up and down stairs

Yes

• May use both the right and left hands interchangeably

Yes

• Exhibits tendencies toward dyspraxia (difficulty with motor planning and coordination)

Yes

• Tense muscles, often stiff, with hypertonia (increased muscle tone)

Yes

• Poor muscle tone, presenting as slouching or hypotonia (decreased muscle tone)

Yes

• Preference for walking on toes

Yes

• Uses W-sitting position

Yes

• Frequently tilts head forward or backward

Yes

• Tends to lay on the desk, often leaning on one arm while lying to the side

Yes

• May wrap legs around the legs of a chair

Yes

• Exhibits signs of disorganization, forgetfulness, and losing track of time

Yes

• Frequently bumps into objects and people

Yes

• Writing and reading may be disorganized, with words running together and lacking spaces between them

Yes

• Experiences frequent letter reversals when reading or writing

Yes

• Difficulty judging space, direction, and distance

Yes

• Takes longer to read, with poor comprehension, and may avoid reading tasks

Yes

• Struggles with math, particularly in organizing numbers and columns

Yes

• Suffers from motion sickness and has a fear of heights

Yes

• Challenges with speech and articulation

Yes

• Difficulty following multiple-step instructions

Yes

• Poor sequencing skills that affect speech, spelling, and composition

Yes

• Difficulty holding still and concentrating for extended periods

Yes

• Struggles to pay attention when the head is down, such as while at a desk or reading

Yes

• May appear disconnected from emotions or feelings

Yes

• Experiences frustration, low self-esteem, and a lack of interest in school

Yes

• Difficulty understanding cause and effect, often making the same mistakes repeatedly

Yes

• Exhibits disorganization and forgetfulness

Yes

--- SGR REFLEX ---

The Spinal Galant Reflex is important for the development of the middle ear, which influences hearing and balance. When retained beyond infancy, it can directly affect a child's attention, focus, and overall coordination. A retained SG reflex can often resemble symptoms of ADHD. Select those that apply.

• Fidgety behavior and inability to sit still, often squirming or displaying hyperactivity

Yes

• Poor concentration and short attention span

Yes

• Struggles with seated posture, whether on the floor or in a chair; often avoids sitting back in the chair

Yes

• Tends to prefer working while standing or lying on the floor

Yes

• Exhibits ADHD-like tendencies (impulsivity, distractibility)

Yes

• Poor bladder control, including bedwetting beyond the age of 5

Yes

• Lack of coordination in both fine and gross motor skills

Yes

• Weak core muscles, contributing to poor posture and balance

Yes

• Difficulty with head control, which may cause tilting of the head to one side

Yes

• Discomfort when touched around the waistline or lower back

Yes

• Struggles with speech clarity or articulation

Yes

• Difficulty with skipping, jumping, or balancing activities

Yes

• Slower work pace, fatigue sets in easily, and slower processing compared to peers

Yes

• Sensory sensitivities, including irritation from tags, belts, or certain textures, as well as discomfort with tight clothing

Yes

• Disorganized and forgetful, often losing track of tasks or belongings

Yes

• Constantly moving or displaying a restless energy (e.g., “ants in the pants”)

Yes

• Digestive issues or irregularities

Yes

• Persistent challenges with balance and poor posture

Yes

• Difficulties with memory or tasks requiring sustained focus and attention

Yes

• Mental fatigue from efforts to concentrate or maintain attention

Yes

--- PALMAR GRASP REFLEX ---

The Palmar Grasp Reflex is a primary motor reflex response to something touching the palm of one's hand just below the base of the fingers. This causes the hand to grasp around the object. This reflex should be active until around 12 months of age. After 12 months of age, one learns to open and release their grip, which is critical for refined fine motor skills and manual dexterity. A retained PG reflex can impact cognitive development. Select those that apply.

• Poor muscle tone and strength

Yes

• Weak fine motor skills

Yes

• Poor motor control and dexterity, including precise movements needed for tasks like writing

Yes

• Poor visual skills (e.g., visual perception, binocular vision, depth perception, eye-hand coordination)

Yes

• Movement overflow: may see the opposite hand that is not engaged in the activity mimicking the task that the engaged hand is performing

Yes

• Delayed speech development

Yes

• Difficulty putting thoughts on paper/dysgraphia

Yes

• Difficulty with self-care skills that require fine motor coordination

Yes

• May have problems with emotional processing and expression (delayed cognitive development)

Yes

• May give up easily (lack of persistence)

Yes

• Difficulty with the concept of "holding on" and "letting go" of things

Yes

• May have difficulty understanding the concept of "holding on" to ideas

Yes

• Difficulty accurately interpreting visual information, such as right and left

Yes

• Challenges in judging distances and depth, impacting coordination

Yes

• Premature or inefficient pencil grasp

Yes

• Poor eye-hand coordination

Yes

--- HANDS PULLING REFLEX ---

The Hands Pulling Reflex appears in utero and should last until around two months of age. The reflex is observed when a baby's hands and wrists are gently pulled, causing the baby to tuck their chin and pull themselves upward into a sitting position. It is the foundation for coordinated movements and motor skills, including handwriting skills. If retained, it may be associated with ADD/ADHD, inability to focus and regulate behavior. Select those that apply.

• Insufficient strength in arms, shoulders, core, and neck muscles

Yes

• Excessive muscle tension or inappropriate muscle tone in arms, hands, neck, and upper body

Yes

• Possible discomfort in arms during drawing or writing tasks

Yes

• Difficulties in activities requiring precise hand movements, such as handwriting and grooming

Yes

• Avoids activities involving hand-eye coordination or body movements using upper body and core strength

Yes

• May struggle to maintain correct arm positioning for tasks involving the use of one's elbows

Yes

--- BABKIN REFLEX ---

The Babkin reflex is also called the "palm-mouth reflex. This reflex should be integrated by four months of age. It encourages palm-to-mouth movements and hand-mouth coordination that contribute to emotional regulation and stress management. Select those that apply.

• Persistent clenching of fists or jaw

Yes

• Craves oral stimulation

Yes

• Difficulty with hand-mouth coordination connected to eating and drinking skills

Yes

• Difficulty with fine motor skills, such as grasping or manipulating small objects

Yes

• Sensory processing issues: over- or under-responsiveness to tactile stimuli

Yes

• Increased anxiety or difficulty in self-regulation

Yes

• Problems with attention and focus due to sensory processing difficulties

Yes