OT Pediatric Evaluation Outline/ Guide

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): _____________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Gross Motor Skills:

(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:___________________________________________________________

 

Additional Comments:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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