Child’s Name:__________________________Completed by:____________________________
Birthdate:___________________
Check the items where the child has difficulty. Refer to Occupational Therapist to determine need for further assessment.
| _____ Fear of new tasks and situations | ______Overly aggressive/explosive |
| _____Overly passive | ______Easily frustrated |
| _____Impulsive | ______Emotionally labile |
| _____Can’t follow directions | ______Unorganized |
| _____Can’t get work done on time | ______Can’t work independently |
| _____Distractable/short attention span | ______Can’t wait/take turns |
| _____Doesn’t learn new activities easily | ______Clumsy |
| _____Tires easily | ______Difficulty hopping, jumping, skipping |
| _____Slouches, poor posture | ______Always something moving(leg, hand, body) |
| _____Poor pencil grasp | ______Poor handwriting |
| _____Breaks pencil or crayon | ______Awkward with pencil/scissors |
| _____Can’t copy from board/book | ______No consistent hand preference |
| _____Letter or number reversals | ______Likes physical contact |
| _____Avoids being touched | ______Dislikes getting hands dirty |
| _____Oral overflow (tongue out, drooling, hands in mouth) | ______Can’t keep hands to self |
| _____Fearful of activities moving through space | ______Poor balance |
| _____Excessive need for swinging, spinning, rocking | ______Delayed speech and language |
| _____Difficulty screening out visual/auditory stimuli | ______Difficulty with dressing skills |
| _____Difficulty discriminating shapes, colors, letters | ______Makes repetitious vocal sounds |
| _____Responds negativity to loud or unexpected noise | ______Positions hands awkwardly |
| _____Walks on toes | ______Rejects textures of food, clothing |
| _____Smells objects | ______Self-stimulation/self-injury |
| _____Grinds, clinches teeth |
Comments:
| © Parent-Child Services Group, Inc. 4/99 |
| Kathy Boling, OTR/L |
| Permission to copy for educational purposes only |