OT Assessment Checklist

Little Big Steps Pediatric Therapy Clinic conducted an occupational therapy assessment of a child. The
assessment evaluated the child's fine motor skills, sensory processing, and motor plann… Full description

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Little Big Steps

PEDIATRIC THERAPY
32A France Street, Better Living Subdivision, Paranaque City
Tel. No. 541-7791 / 09558677650
Email [email protected]

OCCUPATIONAL THERAPY ASSESSMENT

Child’s Name: School:

Date of test: Date of Birth: Age: Male Female
Educaonal Placement: Regular Ed. Special Ed. Inclusion
Evaluang Therapist: Physician’s Referral dated:

DIAGNOSES:

Onset Diagnosis

HISTORY/BACKGROUND INFORMATION:
Remarkable Unremarkable Comments
Family/Social History

Birth History:

Age of Onset:
Medical History:

Allergies:
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Specialists Seen:

Diagnoses:

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Respiration/Cardiovascular

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Auditory:
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Vision:

LITTLE BIG STEPS PEDIATRIC THERAPY CLINIC, INC.

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Medications:
Precautions:

Other Relevant Medical History:

Reason for referral: Fine motor Gross motor Self-help Sensory-motor Visual-motor
Wring Other/Chief Complaints:

Prior therapy: Currently receiving outside therapy at:

Currently receiving therapy through school system:
Other:
Primary means of communicaon: Verbal, language (s):
Non-verbal Pictures Gestures Other:
Tesng Environment: Private Clinic Quiet environment Other:
Family member (s) present:

Behavioral observaon during tesng: Good aenon span Limited aenon span Cooperave
Impulsive Exhibited good eort Lacked eort Engages easily Diculty engaging
Follows verbal direcons Follows demonstraons Responds to redirecon
Doesn’t follow direcons Other:

EVALUATION TOOLS:
Family/Caregiver interview
Clinical Observaon/non-standardized tasks
Standardized Assessment:

SENSORY PROCESSING SUMMARY:

Comments

Auditory: Over Responsive

Under Responsive
Passive
Under Responsive
Seeker

Visual: Over Responsive

Under Responsive
Passive
Under Responsive
Seeker

Tactile: Over Responsive The Tacle system is the largest sensory system of the body. Its
Under Responsive

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Passive
sensory receptors can be located on the skin, inside the mouth,
Under Responsive
throat and digesve tract. The dierent tacle sensaons are
Seeker
vibraon, light touch, deep pressure, temperature and pain.

Oral: Over Responsive

Under Responsive
Passive
Under Responsive
Seeker

Vestibular: Over Responsive The sensory receptors of the vesbular system are located in
Under Responsive the inner ear. It helps maintain our balance and prevents us
Passive from falling. The vesbular system plays a vital role in a child's
Under Responsive physical development. The system is smulated when our head
Seeker posion is changed. Spinning, swinging and looking upside down
provide intense vesbular input. Children who struggle to
process movement informaon from their vesbular systems
may also struggle with bilateral integraon.

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Proprioception: Over Responsive The propriocepve sense provides feedback from our joints and
Under Responsive muscles regarding stretch and force, as well as body posion
Passive and movement of our body through space. The propriocepve
Under Responsive system is smulated when we li, pull and push weighted
Seeker objects. We feel the sensaon on our joints and muscles when
we push joints together, such as when jumping, or pull joints
apart, such as climbing a ladder or hanging on monkey bars.
Intense propriocepve input such as heavy work tasks, appear
to be calming and helps children to self-regulate.

Proprioception: Adequate grasp/release force Inadequate grasp/release force

Grades movements adequately Poor grading of movements Bumps into objects/is clumsy
Enjoys bouncing/crashing into objects Looks at hands during familiar tasks

Comments:

FINE MOTOR SKILLS:

Not applicable

Hand Dominance: Right Le Mixed Undetermined, not an age-appropriate skill

Upper extremity range of moon within funconal limits:
Yes No, explain:
Muscle tone within normal limits: Yes No, explain:
Sing Posture: Funconal Slumps in chair Head on hand Legs wrapped around chair
Constantly shifting/fidgety Posturally insecure Sits on legs
Adaptive seang:

School-aged children should be able to sit with both feet at on the oor with a 90 degree angle at the knees and
hips. This posture improves their aenon and parcipaon in task. Increased ability to maintain proper sing
posture may be due to increased core muscle strength and stability.

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Bilateral Coordinaon: stabilizes/assists with: Other hand Body

Stabilizes adequately Inconsistent stabilizaon Poor use of hands together Does not stabilize
Transfers objects Crosses midline Claps

Grasp of objects: Pincer Lateral Raking Swiping 5 pt 3 pt No grasp

Release of objects: Intact/Voluntary Impaired No release
Reach for objects: Accurate Over/undershoots No reach

In-hand manipulaon: Intact

Diculty with: Shi P-F Translaon F-P Translaon Rotaon

Motor Planning: Iniates acvies Poor approach to tasks Diculty learning new motor tasks
Imitates body postures:
Comments:

Notes:

Crossing the Midline: Crossing the midline happens when your child moves their hand or foot across the
midline to work on the opposite side of their body. Crossing the midline is important
because when children can do this acvity, they are using both sides of their brain to
coordinate smooth, controlled, complex movement. It is important to combine
movement paerns that cross the body for daily tasks such as reading, wring and tying
shoelaces.

Bilateral Integration: Consistency in bilateral coordinaon is important. Being able to coordinate movements
on both sides of the body, whether performing ne motor or gross motor tasks, means
that neural pathways are working together on both sides of the child's brain; that both
sides are able to communicate well in order to gauge the amount of precision, strength
or force needed to perform a task.

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Praxis: Praxis is the ability by which we gure out how to use our hands and body in skilled tasks
such as eang with utensils, play with toys, using a crayon, building with blocks, dressing
ourselves, and engaging in many daily acvies. Praxis involves spontaneously
sequencing and organizing movements in a coordinated manner to complete unfamiliar
motor tasks.

Dexterity: Dexterity is the ability to use your hands skillfully, uently, quickly, and easily.

Cung Skills: Regular scissors Adapted scissors No prior experience

Hand used: Right Le Mixed Both hands on scissors simultaneously
Grasps adequately Stabilizes adequately Needs hand posioned Poor stabilizaon
Diculty placing scissors on paper Diculty with connuous cung
Snips paper Unable to snip Cuts across paper Unable to cut across paper

Cuts straight line on line Cuts straight line within of line Unable
Cuts curved line on line Cuts curved line within of line Unable
Cuts simple shape on line Cuts simple shape within of line Unable
Cuts complex shape on line Cuts complex shape within of Unable
line
Comments:

Handwriting Y I N Comments
Not applicable
Leers formed Boom to top formation Has not learned all letters
correctly Misforms
Leer size adequate Too large
Too small
Leers oriented to Leers o line Needs visual cues (i.e. bold lines,
lines adequately "Go under" leers boxes)
(g, j, p, q, y) o line
"Tall" leers
(b,d,f,h,k,l) o line
Leer spacing is Under spaced Uses nger to space
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adequate Over spaced
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Word spacing is Under spaced

adequate Over spaced
Margins are Doesn’t start at le Dislikes wring or does not want to
adequate margin write
Inadequate space at Poor aenon to writing
end of line
Speed of wring is Takes longer to complete Dislikes wring/does not want to
adequate writing write
Rushes through writing Poor aenon to writing
Quality of wring is Illegible Dependent on aenon to task
adequate Dependent on speed of tasks
Key: Y = Yes I = Inconsistent N = No

Comments:

GROSS MOTOR SKILLS:

Not applicable Refer to Physical Therapy report

Ball skills: Throws ball Unable to throw Catches ball with hands Catches ball against body
Kicks moving ball Kicks staonary ball Ancipates ball Unable to catch Unable to kick

Stairs: Walks up stairs Independently supervised with assistance crawls holds rails
unable
Alternates feet going upstairs two feet per stair going upstairs Did not assess
Alternates feet going downstairs two feet per stair going downstairs Did not assess

Muscle tone within normal limits: Yes No, explain:

Other: Able to hop Able to stand on one foot Able to jump in place
Unable to hop Unable to jump
Comments:

VISUAL PERCEPTUAL SKILLS:

Not applicable
Visual tracking:
Intact Diculty tracking across midline Diculty tracking vercally Unable

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Visual discriminaon – Colors: Intact Not assessed

Matches: Red Blue Green Yellow Emerging Unable
Points to when requested: Red Blue Green Yellow Emerging Unable
Names when pointed to: Red Blue Green Yellow Emerging Unable
Visual discriminaon – Shapes: Intact Not assessed
Matches: Diamond Rectangle Triangle Square Circle Emerging Unable
Points to upon request: Diamond Rectangle Triangle Square Circle Emerging Unable
Names when pointed to: Diamond Rectangle Triangle Square Emerging Unable
Circle
Visual Spaal Relaons: Intact Not Assessed
Disnguishes le from right on self: Yes No
Understands basic direconal terms: Yes Emerging No
Comments:
Able to build: Pyramid Stairs Wall Bridge Train Block tower of blocks
Unable
Completes: Interlocking puzzle Inset puzzle Three shape form board Unable
Body Concept/Body Awareness: Intact Not Assessed
Points to when requested: Mouth Eyes Nose Ears Tongue Head Arms
Hands Fingers Thumb Elbow Legs Knees Feet Stomach Back Unable
Names when pointed to: Mouth Eyes Nose Ears Tongue Head Arms
Hands Fingers Stomach Back
Thumb Elbow Legs Knees Feet Unable
ue Head A
Draw a person includes: Mouth Eyes Nose Ears Tong rms
Stomach Back
Hands Fingers Thumb Elbow Legs Knees Feet Unable
Figure Ground: Intact Not Assessed
Completes a hidden picture: Independently With minimal assist With maximal assist Unable
Completes a word nd: Independently With minimal assist With maximal assist Unable
Comments:

VISUAL MOTOR SKILLS: Intact

Pencil Grasp: Uses right hand Uses le hand Switches hands Uses pencil grasp
Holds pencil near p Holds pencil near distal end Constantly adjusng grasp Hooked
wrist Dynamic tripod Lateral tripod Quadruped Stac tripod Thumb wrap
Thumb tuck Digital pronate (arst’s) Palmar supinate (dagger) Radial cross palmar
Other:
Pencil Pressure: Appropriate Heavy Light

Pre-Wring Strokes T I C Comments

Vercal Line
Horizontal Line Poor adjustment of stroke to line Does not ll enre area
Circle Poor adjustment of stroke to line Does not ll enre area
“+” sign
Square
Diagonal Line
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Triangle
Pre-Wring Strokes T I C Comments
Diamond:
First/Last name
Uppercase Letters
Lowercase Letters
Numbers
Others
Key: T = Traces I = Imitates C = Copies

PLAY:
Preferred Acvies / Toys:

Avoided or Disliked Acvies / Toys:

Quality of Play:

Play Behaviors:

SELF HELP SKILLS: Not applicable

Independent Assisted Comments
Spoon
Fork
Knife
Drink from Cup
Straw
Bottle
Toothbrush
Handwashing
Toileting Wears pull-ups Wears diapers
Indicates when wet: Verbally
Non-verbally
Does not indicate

Inates going to the bathroom: Verbally

Non-verbally
Does not initiate
Shirt
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Socks
Shoes
Zip
Unzip
Button
Unbutton
Snaps
Buckle/Belt
Shoetying

STRENGTHS:

PERFORMANCE IMPAIRMENTS:

RECOMMENDATIONS:

The following Occupaonal Therapy services are recommended:

Direct services at mes/week for months
Other:

Occupaonal therapy will address the following areas:

Fine-motor skills Visual perceptual skills Visual-motor skills Self-help skills
Other:

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PLANNED INTERVENTIONS:

OCCUPATIONAL THERAPY GOALS:

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Signatures: Date:

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