Name:_________________________ Date of Evaluation:_________________
DOB:___________________ Chronological Age:_______________________
Grade:____ School:__________________________ Teacher: _____________
Medications:_______________________________________________________
Concerns:__________________________________________________________
Behaviors Noted at Eval (Level of arousal, affect, attention, etc.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Neuromuscular Status (tone, posture, ROM, etc): _____________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
(Balance)
static sitting ____________________________________________________________
dynamic sitting_________________________________________________________
static standing__________________________________________________________
dynamic standing_______________________________________________________
(Bilateral Coordination)
Jumping Jacks (number of repetitions, quality of movement)
__________________________________________________________________________
Skipping (number of repetitions, quality of movement)
___________________________________________________________________
Bunny Hopping (number of repetitions, quality of movement)
__________________________________________________________________________
Unilateral Hop (number of repetitions, quality of movement)
__________________________________________________________________________
(Trunk Strength)
Supine Flexion (duration, quality of movement)
__________________________________________________________________________
Prone Extension (duration, quality of movement)
__________________________________________________________________________
(Throwing–overhand, underhand, quality of movement, accuracy)
__________________________________________________________________________
(Catching)
(bilateral hands, unilateral hand, quality of movement, accuracy)
__________________________________________________________________________
Fine Motor Coordination:
Hand Dominance_______________________________________________________
Hand Strength__________________________________________________________
Do they cross midline?:_________________________________________________
Bilateral Transfer (quality of movement, cues needed):_______________
__________________________________________________________________________
Bilateral Integration
(stabilizers vs. manipulators– intact, absent, emerging)
__________________________________________________________________________
Developmental Skills:
Shape Sorting: ____________________________________________________
Block Designs:
Tower: (number of blocks) ______________________________________________
3 cube bridge:___________________________________________________________
4 cube train:_____________________________________________________________
6 cube steps:____________________________________________________________
6 step pyramid:__________________________________________________________
Beads:_________________________________________________________________
Lacing:________________________________________________________________
Graphomotor Skills:
Pencil Grasp (tripod, quadropod, thumb wrap, etc):
Prewriting:
Vertical Line: imitates copies traces
Horizontal Line: imitates copies traces
Diagonals: imitates copies traces
Circle: imitates copies traces
Square: imitates copies traces
Cross: imitates copies traces
Coloring:
(cm beyond boundaries, # of times outside of boundary, etc)
__________________________________________________________________________
Writing (pressure, speed)
__________________________________________________________________________
Visuomotor Skills:
Corrective Lenses: yes no
Visual Tracking in 9 cardinal gaze positions:
. . .
Converging/ Diverging: intact absent delayed
Peripheral Vision:
Overhead intact absent delayed
Below intact absent delayed
Right intact absent delayed
Left intact absent delayed
Sensory Integration Skills:
Auditory:
_____Localizes to right and left
_____Consistently responds to name
_____Auditory regard appropriate
Self Regulation
_____Calm
_____Tantrum
Frequency and duration _______________________________________
_____Difficult to redirect/ calm
Arousal Level
_____Appropriate
_____Low
_____High
Tactile System
_____Responds appropriately to input
_____Hypersensitive/ responsive
_____Hyposensitive/ responsive
Proprioception
_____Responds appropriately to input
_____Hypersensitive/ responsive
_____Hyposensitive/ responsive
Vestibular
_____Responds appropriately to input
_____Hypersensitive/ responsive
_____Hyposensitive/ responsive
Activities of Daily Living (FIM scores)
Self feeding:_______________________________________________________
Grooming:_________________________________________________________
Bathing:___________________________________________________________
UB Dressing:______________________________________________________
LB Dressing:_______________________________________________________
Toileting:___________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________