CHILD’S NAME ________________________ ____________________________________ ________________________ ________________ ____ GROSS MOTOR
1.
0.
Climbs on chair or other Elevated piece o !rnit!re li"e a bed #itho!t help al"s bac"#ards
SCO RE
FINE MOTOR
SCO RE
SELF-HELP
SCOR E
SELF-HELP
1.
$ses $ses all all % in in&e &ers rs to &et &et ood'to(s placed )n lat s!race
1.
*eed *eeds s sel sel #it #ith h in in&e &err oo ood d +e.&. bisc!its, bread- !sin& in&ers
1.
/arti /articip cipate ates s #hen bein& bein& dress dressed ed +e.&. rises arms or lits le&-
0.
/ic"s !p ob2ects #ith th!mb and inde3 in&er Disp Displa la(s (s a de dein ine e han hand d preerence /!ts /!ts sma small ll ob2 ob2ec ects ts in' in'o! o!tt o containers
0.
*eed *eeds s sel sel !si !sin& n& spoo spoon n #it #ith h spilla&e *eed *eeds s sel sel !si !sin& n& spoo spoon n #it #ith h spilla&e *eed *eeds s sel sel !sin !sin& & in& in&er ers s #itho!t spilla&e
1%.
/!lls /!lls do#n do#n &art &artere ered d short short pants pants
16. 16.
5emo 5emove ves s san sando do
17.
Dresse Dresses s #itho!t #itho!t assis assistan tance ce e3cept e3cept b!ttons and t(in&
Hold Holds s cra cra(o (on n #ith #ith all all the the in&ers o his hand ma"in& a irst +i.e. palmer &rasp$nsc $nscre re#s #s lid lid o o con conta tain iner er or !n#raps ood
%.
*eed *eeds s sel sel !sin !sin& & in& in&er ers s #itho!t spilla&e
18.
Dresses Dresses #itho!t #itho!t assistance assistance incl!din& incl!din& b!ttons and t(in&
6.
Eats Eats #ith #itho! o!tt nee need d or or spoo spoon n eedin& d!rin& an( meal
19.
Inorms Inorms the ad!lt ad!lt onl( onl( ater ater he has alread( $rinated +peed- or moved his bo#els +poohedIn his !nderpants Inorms ad!lt o need to !rinate +pee- or move bo#els +pooh;poohso he can be bro!&ht to a Desi&nated place + e.&. comort room=oes to the desi&nated place to !rinate +pee- or move bo#els +poohb!t sometimes she does this in his !nderpants =oes to the desi&nated desi&nated place to !rinate +pee- or move bo#els +poohand never does this in his !nderpants ipes'Cleans sel ater a bo#el movement +pooh-
5!ns #itho!t trippin& or allin& al"s do#n stairs, 0 eet on each step #ith one hand held al"s !p stairs holdin& handrail, 0 eet on each step al"s !pstairs #ith #ith alternate eet itho!t holdin& handrail
4.
7.
al"s do#nstairs #ith alternate eet #itho!t holdin& handrail
7.
Scribbles spontaneo!sl(
7.
Helps hold c!p or drin"in&
0:.
8.
Moves bod( part as directed
8.
Scri Scribb bble les s vert vertic ical al and and hori
8.
Drin"s rom c!p #ith spilla&e
01.
4. . %. 6.
. %. 6.
4. .
9.
>!mps !p
9.
Dra#s circle p!rposel( p!rposel(
9.
Drin"s rom c!p !nassisted
00.
1 :.
?hro#s ball overhead overhead #ith direction
1:.
1:.
=ets drin" or sel !n assisted
04.
1 1. 1 0. 1
Hops 1 or 4 steps on preerred oot
11.
Dra#s Dra#s a h!man h!man i&! i&!re re +head +head,, e(es arms, Hands, in&ersDra#s Dra#s a ho!s ho!se e !sin& !sin& &eom &eometr etric ic *orms
11.
/o!rs /o!rs rom rom pitch pitcher er #ith #itho!t o!t spilla&e
0.
/arti /articip cipate ates s #hen #hen bathin bathin& & + e.&. r!bbin& arms #ith soap
10.
/repares o#n ood snac"
0%.
ashes and dries hands #itho!t an an( help
14.
/repares /repares meals or (o!n&er (o!n&er
06.
ashes ashes ace #itho!t #itho!t an( help
>!mps and t!rns TOTAL
Dances Dances patterns patterns '2oins '2oins
SCO RE
4.
&ro!p movement activities
siblin&s'amil( members #hen no ad!lt is aro!nd 07.
@athes #itho!t an( help
TOTAL TOTAL
CHILD’S NAME ____________________________________________________
1.
RECEPTIVE
SCO
LANGUAGE
RE
SEF-HELP
SELF-HELP
E
/oints to amil( member #hen as"ed to do so /oints to % bod( parts on himsel #hen as"ed to do so
1.
4.
/oints to % named pict!red ob2ects #hen as"ed to do so
.
*ollo#s one;step instr!ctions that incl!de simple prepositions + e.&. in, on, !nder, etc.*ollo#s 0;step instr!ctions that incl!de simple prepositions
0.
SCOR
SCOR E
Loo"s at direction o allen ob2ect Loo"s or partiall( hidden ob2ect
17.
Can assemble simple p!<
1:.
18.
Demonstrate an !nderstandin& o opposites b( completin& a statement +e.&. An& aso a( mala"i, an& da&a a(___
11.
4.
Imitates behavior 2!st seen s e# min!tes earlier
19.
/oints to let and ri&ht sides o bod(
10.
.
)ers ob2ect b!t #ill not release it
0:.
Can state #hat is sill( or #ron& #ith pict!res +e.&. Ano an& mali sa lara#an& ito-
14.
Comorts pla(mates'siblin& in distress
%.
Loo"s or completel( hidden ob2ect
01.
Matches !pper and lo#er case letters
1.
/ersists #hen aced #ith a problem or obstacle to his #ants
6.
E3hibits simple pretend pla(+*eed, p!t doll to sleepMatches ob2ects
1%.
Helps #ith amil( chores +e.&. #ipin& tables, #aterin& plants, etc.-
0.
Imitates ad!lt activities +e.&. coo"in&, #ashin& Identiies eelin&s in others
Appropriatel( !ses c!lt!ral &est!res o &radin& #itho!t m!ch promptin& + e.&. more, bless, "iss, etc.
%.
TOTAL
7. EXPRESSIVE LANGUAGE
1. 0. 4.
$ses %;0: reco&ni
TOTAL
SCO RE
SOCIO-EMOTIONAL
SCOR E
16.
C!rio!s abo!t environment b!t "no#s #hen to stop as"in& !estions o ad!lts
8.
Matches 0;4 colors
1.
En2o(s #atchin& activities o nearb( peoples and animals
17.
aits or his t!rn
9.
Matches pict!res
0.
18.
As"s permission to pla( #ith to( bein& !sed b( another
1:.
Sorts based on shapes
4.
*riendl( #ith stran&ers b!t initiall( ma( sho# sli&ht an3iet( or sh(ness /la(s alone b!t li"es to be
19.
Deends possessions #ith
no!n combinations + e.&. hin&i &atasSorts ob2ects based on 0 attrib!tes +e.&. si
.
near amiliar ad!lts or brothers and sisters La!&hs or s!eals lo!d in pla(
%.
/la(s pee";a;boo +b!la&a-
01.
1 4.
N am es ; 6 c ol or s
6.
/oles ball interactivel( #ith care&iver'e3aminer
00.
Honors a simple bar&ain #ith care&iver +e.&. can pla( o!tside onl( ater cleanin&'i3in& his room-
1 .
C opi es s ha pes
7.
H!&s or c!ddles to(s
04.
atches responsibl( over (o!n&er siblin&'amil( members
1%.
Names 4 animals or ve&etables #hen as"ed
8.
Demonstrates respect or elders !sin& terms li"e Bpo and Bopo
0.
Cooperates #ith ad!lts and peers in &ro!p sit!ations to minimi
16.
States #hat common ho!sehold items are !sed or
9.
Shares to(s #ith others
11.
. %.
Names ob2ects in pict!res Spea"s in &rammaticall( correct 0;4 #ord sentences
6.
As"s B#hat !estions
7.
As"s B#ho and B#h( !estions =ives acco!nt o recent e3periences +#ith promptin&- in order o occ!rrence !sin& past tense
8.
TOTAL
10.
determination 0:.
/la(s or&ani
TOTAL
