Departemen Ilmu Kesehatan Anak Tanggal : 4-5-2015 Nama :

Leonel Alvaro
RS WAHIDIN SUDIROHUSODO, MAKASSAR Dokter : Tanggal Lahir : 1-5-
2015
No RM : 710741 Jenis Kelamin :L

ADAPTIVE SKILL CHECKLIST FOR 3 TO 5 YEARS (ADL)

Parent: Please complete the following items:

Yes Some Not Yet Dev Age

times
1. Does your child know he/she is wet/dirty? 15
2. Does your child help with dressing by pushing arms and legs through clothing? 24
3. Does your child feed him/herself with a spoon? 24
4. Does your child put on shoes/boots by him/herself (may not be on the right feet)? 29
5. Does your child drink from a regular cup (without a top) without spilling? 30
6. Does your child use the toilet if taken? 30
7 Does your child put toys where they belong when asked? 30
8 Does your child move around the house by him/herself without needing to be 30
watched?
9 Does your child undress with no help? 36
10 Does your child put on an open-front shirt or coat with no help? 36
11 Does your child feed him/herself with a fork? 36
12 Does your child know what to do when hungry or thirsty (Le., ask for a snack or get 36
him/herself a snack/drink)?
13 Does your child help with brushing teeth or hair? 36
14 Does your child stay, with you in public places? 36
15 Does your child show caution and avoid common dangers (i.e., hot stove, moving 36
cars)?
16 Does your child use the toilet without being reminded? 42
17 Does your child control his/her bladder during the day? 42
18 Does your child control his/her bowels during the day? 48
19 Does your child wash and dry his/her hands? 48
20 Does your child tell an adult when feeling sick, tired or scared? 48
21 Does your child eat a variety of food types and textures? 48
22 Does your child prepare his/her own snacks (i.e., peel banana, take wrapper off) 48
23 Does your child wash or wipe face? 50
24 Does your child blow his/her nose with help? 54
Total
(R:6/11 - C:6/11) white Early Childhood CARES form Child Development & Disabilities

Scoring: Total the number of "yes", "sometimes" and "not yet" using 2 points for "yes", 1 point for "sometimes" and 0 for "no". Using the
chart below, compare the child's total points to the total for his/her age range and the recommended referral range for example, if child is
36 months and had a score of 26, a referral would not be recommended.

Age Possible Child's Referral

Range Points Points Recommended

36 months 30 20 or less

36-42 months 34 22 or less

42-48 months 44 28 or less

48-54 months 48 33 or less