CHILDS NAME ____________________________________________________ GROSS MOTOR 1.

Climbs on chair or other Elevated piece o !rnit!re li"e a bed #itho!t help 1al"s bac"#ards 5!ns #itho!t trippin& or allin& 1al"s do#n stairs, 0 eet on each step #ith one hand held 1al"s !p stairs holdin& handrail, 0 eet on each step 1al"s !pstairs #ith alternate eet 1itho!t holdin& handrail 1al"s do#nstairs #ith alternate eet #itho!t holdin& handrail Moves bod( part as directed >!mps !p

SCO RE
1.

FINE MOTOR
$ses all % in&ers to &et ood'to(s placed )n lat s!r ace /ic"s !p ob2ects #ith th!mb and inde3 in&er Displa(s a de ine hand pre erence /!ts small ob2ects in'o!t o containers Holds cra(on #ith all the in&ers o his hand ma"in& a irst +i.e. palmer &rasp$nscre#s lid o container or !n#raps ood

SCO RE
1.

SELF-HELP
*eeds sel #ith in&er ood +e.&. bisc!its, bread- !sin& in&ers *eeds sel !sin& spoon #ith spilla&e *eeds sel !sin& spoon #ith spilla&e *eeds sel !sin& in&ers #itho!t spilla&e *eeds sel !sin& in&ers #itho!t spilla&e Eats #itho!t need or spoon eedin& d!rin& an( meal

SCOR E
1..

SELF-HELP
/articipates #hen bein& dressed +e.&. rises arms or li ts le&/!lls do#n &artered short pants 5emoves sando Dresses #itho!t assistance e3cept b!ttons and t(in& Dresses #itho!t assistance incl!din& b!ttons and t(in& In orms the ad!lt onl( a ter he has alread( $rinated +peed- or moved his bo#els +poohedIn his !nderpants In orms ad!lt o need to !rinate +pee- or move bo#els +pooh;poohso he can be bro!&ht to a Desi&nated place + e.&. com ort 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 place to !rinate +pee- or move bo#els +poohand never does this in his !nderpants 1ipes'Cleans sel a ter a bo#el movement +pooh/articipates #hen bathin& + e.&. r!bbin& arms #ith soap 1ashes and dries hands #itho!t an( help 1ashes ace #itho!t an( help

SCO RE

0. 4. .. %. 6.

0. 4. .. %. 6.

0. 4. .. %. 6.

1%. 16. 17. 18. 19.

7.

7.

Scribbles spontaneo!sl(

7.

Helps hold c!p or drin"in&

0:.

8.

8.

Scribbles vertical and hori<ontal lines Dra#s circle p!rposel(

8.

Drin"s rom c!p #ith spilla&e

01.

9.

9.

9.

Drin"s rom c!p !nassisted

00.

1 :. 1 1. 1 0. 1

?hro#s ball overhead #ith direction Hops 1 or 4 steps on pre erred oot >!mps and t!rns

1:. 11.

Dra#s a h!man i&!re +head, e(es arms, Hands, in&ersDra#s a ho!se !sin& &eometric *orms TOTAL

1:. 11. 10. 14.

=ets drin" or sel !n assisted /o!rs rom pitcher #itho!t spilla&e /repares o#n ood snac" /repares meals or (o!n&er

04. 0.. 0%. 06.

Dances patterns '2oins

4.

&ro!p movement activities

siblin&s' amil( members #hen no ad!lt is aro!nd

07. @athes #itho!t an( help

TOTAL TOTAL

CHILDS NAME ____________________________________________________ RECEPTIVE LANGUAGE

1. 0. /oints to amil( member #hen as"ed to do so /oints to % bod( parts on himsel #hen as"ed to do so /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

SCO RE
1. 0.

SEF-HELP
Loo"s at direction o allen ob2ect Loo"s or partiall( hidden ob2ect Imitates behavior 2!st seen s e# min!tes earlier ) ers ob2ect b!t #ill not release it Loo"s or completel( hidden ob2ect E3hibits simple pretend pla(+*eed, p!t doll to sleepMatches ob2ects

SCOR E
17. 18.

SELF-HELP
Can assemble simple p!<<les
Demonstrate an !nderstandin& o opposites b( completin& a statement +e.&. An& aso a( mala"i, an& da&a a(___

SCOR E
1:. 11. Imitates ad!lt activities +e.&. coo"in&, #ashin& Identi ies eelin&s in others

4.

4.

19.

/oints to le t and ri&ht sides o bod( Can state #hat is sill( or #ron& #ith pict!res +e.&. Ano an& mali sa lara#an& itoMatches !pper and lo#er case letters

10.

Appropriatel( !ses c!lt!ral &est!res o &radin& #itho!t m!ch promptin& + e.&. more, bless, "iss,
etc.

..

..

0:.

14.

Com orts pla(mates'siblin& in distress /ersists #hen aced #ith a problem or obstacle to his #ants Helps #ith amil( chores +e.&. #ipin& tables, #aterin& plants, etc.C!rio!s abo!t environment b!t "no#s #hen to stop as"in& A!estions o ad!lts 1aits or his t!rn As"s permission to pla( #ith to( bein& !sed b( another De ends possessions #ith

%.

%. 6.

01.

1.. 1%.

TOTAL
7.

TOTAL

EXPRESSIVE LANGUAGE
1. 0. 4. $ses %;0: reco&ni<able #ords $ses prono!ns +e.&. I. me, a"o, a"in$ses 0;4 #ords verb;

SCO RE
8. 9. 1:.

SOCIO-EMOTIONAL
Matches 0;4 colors Matches pict!res Sorts based on shapes
1. 0. 4. En2o(s #atchin& activities o nearb( peoples and animals *riendl( #ith stran&ers b!t initiall( ma( sho# sli&ht an3iet( or sh(ness /la(s alone b!t li"es to be

SCOR E

16. 17. 18. 19.

no!n combinations + e.&. hin&i &atas.. %.

Names ob2ects in pict!res Spea"s in &rammaticall( correct 0;4 #ord sentences 11. 10. Sorts ob2ects based on 0 attrib!tes +e.&. si<e and colorArran&es ob2ects accordin& to si<e rom smallest to bi&&est Names .;6 colors Copies shapes Names 4 animals or ve&etables #hen as"ed

.. %. 6. 7. 8.

near amiliar ad!lts or brothers and sisters La!&hs or sA!eals lo!d in pla( /la(s pee";a;boo +b!la&a/oles ball interactivel( #ith care&iver'e3aminer H!&s or c!ddles to(s Demonstrates respect or elders !sin& terms li"e BpoC and BopoC Shares to(s #ith others

determination 0:. 01. 00. 04. 0.. /la(s or&ani<ed &ro!ps &ames airl( + e.&. does not cheat in order to #in Can tal" abo!t di ic!lt eelin&s +e.&. an&er, sadness, #orr(- he e3periences
Honors a simple bar&ain #ith care&iver +e.&. can pla( o!tside onl( a ter cleanin&' i3in& his room-

6. 7. 8.

As"s B#hatC A!estions As"s B#hoC and B#h(C A!estions =ives acco!nt o recent e3periences +#ith promptin&- in order o occ!rrence !sin& past tense TOTAL

14. 1.. 1%.

1atches responsibl( over (o!n&er siblin&' amil( members Cooperates #ith ad!lts and peers in &ro!p sit!ations to minimi<e A!arrels and con licts

16.

States #hat common ho!sehold items are !sed or

9.

TOTAL