INITIAL EVALUATION FORM

Name: _____________________________ Date: _____________

Chronological Age: ______ ______ ______

Describe a typical day for the child.

What are the child’s interests/hobbies?

What are your child’s strengths?

What barriers are affecting his/her success?

What are your goals for therapy?

Social-Emotional/Behavior
Affect: appropriate flat labile
friendly withdrawn reacts well to praise

fearful fussy difficulty separating

easily separates

Concentration: appropriate distractible responds well to direction

Response to Environment: poor safety awareness appropriate response to stimuli brief eye contact
unaware of objects aware of objects provides eye contact
unaware of people aware of people

Approach to Task: independent impulsive/disorganized says “I can’t”

Coping: cooperative/accepts limits unable to accept direction low frustration tolerance

aggressive

Directions/Cueing: follows verbal directions follows visual directions follows physical directions
follows 1-step directions follows 2-step directions follows 3-step directions
unable to follow directions

Transitions: independently with minimal redirection with moderate redirection

with maximal redirection

Attention to Task: sustain for entire task sustain for 50% of task sustain for 25% of task
Unable to sustain attention

Fine Motor Skills

In-hand muscles: open partially open hands fisted
indwelling thumb decreased creased decreased web space
atrophy of thenar atrophy of hypothenar

Reach: visual regard to objects activates hand to object hand-to-mouth

swatting no reach

Grasp: reflex used reflex integrated no grasp

Grasp Pattern: gross raking radial hand use

3 jaw chuck ulnar hand use neat pincer
lateral pincer inferior pincer

Grasp on Writing Utensil: uses R hand uses L hand uses both hands
 gross grasp proximal end distal end
dynamic tripod static tripod digital pronate

Release: intact/voluntary impaired no release

Midline Orientation: hands at midline holds object at midline

Crossing Midline: freely only to one side (L or R) needs facilitation

Bilateral Transfer: intact impaired emerging

Bilateral Integration: present absent emerging

(Stabilizer v. Manipulator)

In-hand manipulation: translation rotation shift

Hand dissociation: present absent

Arm dissociation: present absent

Dominance: Left Right Emerging

Gross-Motor
Posture
Core strength (superman pose)
Body Awareness (Simon Says)
UB Coordination
Drop/Catch ball
Catch ball
Dribbling ball
Throwing ball at target

Play Skills
mouths bangs throws cause & effect
pretend play parallel play plays with others

Sensory
Self-regulation: calm tantrums frequently difficult to calm
Arousal level: appropriate low high
Activity level: appropriate hyperactive hypoactive
Response:
Auditory
Visual
Tactile
Movement
Oral
ACTIVITES
Drawing
Draw A Person--
Imitate vertical strokes—
Imitate horizontal strokes—
Copy Circle—
Copy Cross—
Trace line—
Copy Square—
Connect 2 dots—
Color between lines—
Mazes—
Hidden picture—
Find the difference--

Writing Name

Scissors
Snip--
Cut in half--
Cut on line--
Cut Circle--
Cut Square--

Paper Folding
Hot-dog--
Hamburger--

Pegs--

Puzzle--

Blocks
Tower--
Pattern--
Design-- Train Stairs Pyramid

Stringing Beads--

Lacing—

Game-- Turn-taking Following Rules

Self-Care
Feeding--

Dressing
Buttons--
Zipper--
Snaps--
Shoes--