Sociodemographic Profile

Indicate the complete sociodemographic profile of the child

Child's Name: ___________________________________ Sex: ___ Date of Birth: ___________________

Address: ________________________________________________________________________________
Barangay Municipality/City Province Region
Child's Handedness (Check appropriate box) Right Lef

Both Not yet

established
Is the child presently studying? (Check appropriate box) Yes No
If yes, write name of child's school/learning center/day care: ________________________________

Father's Name: ________________________________ Father's Age: ___________

Father's Occupation: ___________________________ Father's Educational Attainment: ___________

Mother's Name: _______________________________ Mother's Age: __________

Mother's Occupation: __________________________ Mothe's Educational Attainment: ___________
Child's Number of Siblings:______________________ Child's Birth Order (1st, 2nd, 3rd, etc):_______

4
5

10
10

11

12

13

3
4

10

11
1

10

11

12

13

14

15

16

17
17

18

19

20

21

22

23

24

25

26

27

Receptive Language
1

Expressive Language

7
8

Cognitive

5
 Cognitive

10

11

12

13

14
 Cognitive

15

16

17

18

19

20

21

Socio-Emotional

4
5

10

11

12

13

14

Socio-Emotional

15

16

17

18

19

20
 21

22

23

24

Name of Examiner: _
Date administered: _
Place where tests is a

To the examiner:
Write down your not

Child's background (e
_________________
_________________
_________________
_________________
_________________

Family environment (
_________________
_________________
_________________
_________________
_________________

Parents stimulating a
stimulate the child's d
_________________
_________________
_________________
_________________
_________________

Home environment (
_________________
_________________
_________________
_________________
_________________

Others:
_________________
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_________________
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 Year Month Day
Examiner's Name
Date Tested
1st assessment Child's Date of Birth
Child's Age

Date Tested
2nd assessment Child's Date of Birth
Child's Age
Date Tested
3rd assessment Child's Date of Birth
Child's Age

Depart
ment of
Departm Social
Department of Education ent of Welfare
Health and
Develo
pment

Gross Motor Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.
Climbs on chair or
other elevated piece
Parental report will suffice
of furniture like a bed
without help

MATERIAL: Toy
PROCEDURE:
Ask the child to walk backwards by
Walks demonstrating this.
backwards Credit if the child is able to walk
backwards with-out falling and holding on to anything.
Parental report will suffice.

MATERIAL : Ball
Runs without PROCEDURE:
tripping or falling Encourage the child to run by rolling a ball across the
floor.
Credit if the child run fast and smoothly withour
tripping or falling.
Walks downstairs
with one hand Automatically credit if item #6 is passed.
held Parental report will suffice.
 MATERIAL: Toy
PROCEDURE:
Place a toy in the middle of the 4th or 5th step
Walks upstairs and ask the child to walk up stairs to get the toy. Credit
holding onto a if the child walks up stairs using the handrail or wall for
handrail, 2 feet on support and places both feet on each step before
each step stepping on the next one. Automatically credit if #6 is
passed. Parental
report will suffice

MATERIAL: Toy
Walks upstairs with PROCEDURE:
alternate feet Place a toy in the
without holding onto middle of the 4th or 5th step and ask the child to walk
a handrail upstairs to get the toy.
Credit if the child walks upstairs, alternating
his feet as he steps on each successive step without
holding onto the handrail or wall for support. Parental
report will suffice

MATERIAL: Toy
PROCEDURE:
Place a toy at the bottom of the stairs and ask the child
Walks downstairs
with alternate feet to walk downstairs to get the toy. Credit if the child
without holding onto walks downstairs alternating his feet as he steps on each
successive step without holding onto the handrail or
a handrail wall for support. Do not give credit if the child places
both feet on the step or uses the handrail or wall for
support. Parental report will suffice

Moves body part PROCEDURE:

as directed Ask the child to raise both arms
Jumps up This must be elicited by the interviewer

Gross Motor Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.

MATERIAL: Toy PROCEDURE:

Give the child the ball
and stand at least 3 feet away from him. Ask the child to
Throw ball throw the ball to you using an overhand throw. You may
overhead with show the child how to do it. Credit if the child throw the
direction ball within your ams, reach between your knees and
 MATERIAL: Toy PROCEDURE:
Give the child the ball
and stand at least 3 feet away from him. Ask the child to
Throw ball throw the ball to you using an overhand throw. You may
overhead with show the child how to do it. Credit if the child throw the
direction ball within your ams, reach between your knees and
head using an overhand throw and not sideways or
underhand

PROCEDURE: Ask
the child to lif his food and hop atleast 3 times on his
Hops 1 to 3 steps on preferred foot. Credit if the child is able to jop atleast 3
preferred food times on his preferred foot without holding into
anything

Jumps and turns PROCEDURE: Ask

the child to jump wjile making a half turn. Credit the
child if able to do this without tripping or falling.

Dances patterns/joins Parental report will suffice

group
movement activities
TOTAL SCORE

Fine Motor Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.
MATERIAL: Small toy/object
PROCEDURE:
Uses all 5 fingers to get level withSet the child on the parents lap woth his elbows at
table top and his hands on the table flat surface.
food/toys placed on a Drop a small toy in front of him and attract his attention by
flat surface pointing on top or tapping the table/flat surface. Credit if the
child uses the tips of his thumb and index or forefinger to pick
up the toy food

MATERIAL: Any toy or object

PROCEDURE:
Picks up object with Place a toy/food in front of the child and within his
tumb and index finger reach. Attract his attention by tapping near the toy/food. Credit
if the child uses the tips his thumb and index or forefinger to
pickup the toy/food

Display a definite hand MATERIAL: Small object, container

preference PROCEDURE: Place a toy directly infront of the child at midline
(not to his lef or his right) and ask him to reach for this. Credit
if he uses the same hand, 2 out of 3 times.
Parental report will
suffice
Puts small objects in/out MATERIAL: Toy
of containers PROCEDURE:
This must be elicited by the interviewer

MATERIAL: Crayon
PROCEDURE:
Holds crayons with all Present the child with crayon and have him
the fingers of his hands get this. (Credit child if he holds it by wrapping all five fingers
as though making a fist around as if making a fist. Automatically credit this item if he
(i.e., palmar grasp) uses the tips of all five fingers or his thumb, index and middle
fingers) This
must be elicited by the interviewer

Unsrew the lid of a

container or unwraps MATERIAL: container with screw on top or wrapped candy
food
This must be elicited by the interviewer

MATERIAL: Paper, pencil/crayon

PROCEDURE:
Place a piece of paper and pencil/crayon on the table
Scribbles spontaneously and ask the child to draw anything he wants without showing
him what to do. Credit if the child uses tips of his thumb and
any of his other fingertips to grasp the pencil/crayon and
purposefully scribbles on the paper. (not accidentally)

Fine Motor Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.

MATERIAL: Paper, pencil/crayon

PROCEDURE:
Place a piece of paper and pencil/crayon on the table or
flat surface and ask the child to draw vertical and horizontal
Scribbles vertical and lines afer you demonstrated these to him. Credit if the child
horizontal lines produces a vertical or horizontal line that is atleast 2 inches
long does not deviate or vary from your vertical line by more
than 30 degrees. T by more than 30 degrees. The lines may be
wavy but not broken

MATERIAL: Paper, pencil/crayon

PROCEDURE:
Place a paper and pencil/crayon on the table or flat
Draw circle purposefully surface and ask the child to draw a circle or a ball afer you
demonstrated it to him. Credit if the child produce any curve
that is closed or nearly closed. Continous spiral motions are not
credited.

Draw a human figure MATERIAL: Paper, pencil

(hea, eyes, trunks, arms, PROCEDURE:
hand, fingers) Give the child a pencil a paper and ask him to
draw a picture of a person. Credit if the child has drawn 3 or
more body parts. A pair is considerede one part (eyes, ears,
arms, hands, legs and feet) and must be drawn in pairs to get
full credit unl;ess the drawing is in profile

Draw a house using MATERIAL: Paper, pencil

geometricnforms PROCEDURE:
Give the child a pencil a paper and a paper and
ask him to draw a picture of a house. Credit if the child has
drawn atleast the roof, main frame, and a door and a window.
 TOTAL SCORE

Self-Help Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.
Feeding sun-domain

Feeds self with finger MATERIAL: Bread, biscuit

foods (e.g., biscuits, This must be elicited by the interviewer
bread) using finger

Feeds self using fingers

to eat rice, viands with Parental report will suffice
spillage

Feeds self using spoon Parental report will suffice

with spillage
Feed self using finger Parental report will suffice
without spillage

Feed self using spoon Parental report will suffice

without spillage

Eats without need for

spoon feeding during any Parental report will suffice
meal
MATERIAL: Drinking cup, water
Helps hold cup for Note: The cup should not have a lid or spout
drinking This must be elicited by the
interviewer
MATERIAL: Drinking cup, water
Drinks from cup with Note: The cup should not have a lid or spout
spillage This must be elicited by the
interviewer Automatically credits if he passes the
next item
Drinks from cup with MATERIAL: Drinking cup, water
unassisted This must be elicited by the interviewer
Get drink for self
Parental report will suffice
unassisted
Pours from pitcher Parental report will suffice
without spillage

Ask the caregiver if the child can prepare his own snack
Prepares own food/snack without help except for getting items that are hard to reach
(e.g. bowl, spoon)

Prepares meals for

younger siblings/family Parental report will suffice
members when no
adults around

Dressing sub-domain

Participates when being

dressed (e.g raises arms Parental report will suffice
or lif leg.

Pulls down gartered Parental report will suffice

short pants
Removes sando Parental report will suffice

Self-Help Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.
Dresses without Parental report will suffice
assistance for buttoning
and tying
 Dresses without Parental report will suffice
assistance for buttoning
and tying

MATERIAL: Small shirt w/ button and shoe w/ shoestring

Dresses without PROCEDURE:
assistance including How the child demonstrate how to button and tie to
buttoning and tying credit this item

Toilet Training
sub-domain

Informs the adults only

afer he has already
urinated (peed) or
moved his bowels, Parental report will suffice
(poohed) in his
underpants (e.g.
conmfort room)

Informs the adults of

need to urinate (pee) or
move bowels, (pooh-
Parental report will suffice
pooh) so he can be
brought to a designated
place

Goes to the designated

place to urineated (pee)
or move bowels (pooh) Parental report will suffice
but sometimes still does
this in his underpants

Goes to the designated

place to urineated (pee)
or move bowels (pooh) Parental report will suffice
and never does this in
his underpants anymore

Wipes/cleans self afer a

bowel movement (pooh) Parental report will suffice

Bathing sub domain

Participates when
bathing (e.g. rubbing Parental report will suffice
arms with soap)

Washes and dries hands Ask the caregiver if the child can wash and dry his hands
without help or supervision except to turn on/off faucets that
without any help are out or reach

Ask the caregiver if the child can wash and dry his face without
Washes face without any help or supervision except to turn on/off faucets that are out or
help reach

Bathes without help Parental report will suffice

TOTAL SCORE

Receptive Language Material/Procedure Present Comments

 1st Eval. 2nd Eval. 3rd Eval.
PROCEDURE:
Ask the child to point to mother/caregiver
Point to a family member Credit if he does go
when asked to do so

Points to 5 body parts on PROCEDURE:Have the child point to his eyes, nose, mouth,
himself when asked to hands and feet.
do so Credit if he can point to all these

MATERIAL: Picture book 1

PROCEDURE: Show the child a picture book (2 pictures per
Points to 5 named page) and ask him to point to the picture by saying "Where's
pictured objects when the ____".
aked to do so Credit if the child can use his fingers to point to atleast 5
pictures.

MATERIALS: Block/toy
Follows one-step PROCEDURE:
instructions that include Ask the child to put a block/toy under the table, on
simple preposition (e.g. the table, in the bag. Do not point or use gestures when giving
in, on, under, etc.) the instructions. Credit if the child is able to follow at least one
of the instruction

MATERIAL: Block/toy
PROCEDURE:
Follows 2 step Ask the child to get a block/toy from under the table
instructions that include and then place it on the table. Do not point or use gestures
simple prepositions when giving the instruction.
Credit if the child is able to follow.

TOTAL SCORE

Expressive Language Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.
PROCEDURE: Ask the caregiver if the child can clearly say 5 to 6
words aside from "mama" and "papa". This will be minimum
Uses 5 to 20 number
recognizable words

Uses Pronous (e.g. I, me, Parental report will suffice

ako, akin)

Uses 2 to 3 word verb

noun combinations (e.g. Parental report will suffice
bingi, gatas)

MATERIAL: picture book 2

POCEDURE:
Name objects in pictures Show the child a picture book, point to an object in the
book, then ask him to name it (e.g. " Ano to"). Credit if the
child can say the correct name of atleast 4 object

Speaks in grammatically
correct 2 to 3 wod Parental report will suffice
sentences

Ask "what" questions Parental report will suffice

Ask "who" and "why" Parental report will suffice
questions
 PROCEDURE: Ask the caregiver if the child can recount recent
experience in correct sequence and using past tense correctly.
Gives account of recent The caregiver can prompt him so he can complete what he is
experiences (with talking about (e.g. tapos ano pang nangyari?)
prompting) in oredr of Parent report will
occurrence using past suffice.
tense

TOTAL SCORE

Cognitive Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.
MATERIAL: spoon/ball
PROCEDURE:
With the child seated, get his attention and drop a
Looks in the direction of spoon/ball in front on him. Then observed if his eyes look
fallen object
down as it falls. Credit if the child can bring his eyes and head
down as the object falls. Automatically credit of item #5 is
passed.

MATERIAL: ball, small towel/cloth

PROCEDURE:
Looks for a partially With a child facing you, partially hide a ball behind him a
hidden object small towel and observe if he will look for and find it. Credit if
the child pulls the towel and gets the hidden ball. Automatically
credit if item #5 is passed.

Imitates behavior just

Automaticall credit if item #6 is passed.
seen a few minutes Parental report will suffice
earlier

Offers an object may not Parental report will suffice

release it

MATERIAL: ball, small towel/cloth

PROCEDURE:
Look for a completely
With a child facing you, hide a ball completely under a
hidden object small towel and observe if he will look under the towel. Credit
if he looks under the towel and gets the hidden ball.

MATERIAL: doll or toy car/blocks

Exhbits simple "pretend" PROCEDURE:
play (feeds, puts doll to If the child is a girl, carry the doll and pretend to
sleep) rock it ti sleep. If the child is a boy, move the toy car/block back
and forth. Credit if the child can initiate this.

MATERIAL: pair of spoon, balls, blocks

PROCEDURE:
Place 1 spoon, 1 ball and 1 block on the table. Give the
child the other set of objects, arranged in random order.
Matches objects Demonstrate a matching response (e.g. spoon to spoon) ten
return the objects to the child. Say, "Put each object on the
one that is just like it". Credit if the child can match the objects
correctly.

MATERIAL: 3 pairs of crayons (blue, red, yellow) PROCEDURE:

Place 1
crayon of each color on the table or flat surface. Give the chile
the other crayons arranged in random order. Demonstrate a
Matches 2 to 3 colors matching response (e.g. red crayon with another red crayon)
ther return the crayons to the child. Say " Put each crayon on
the one that is just like it". Credit if the child can match all
colors correctly.

TOTAL SCORE
 Cognitive Material/Procedure Present Comments
1st Eval. 2nd Eval. 3rd Eval.

MATERIALS: 3 pairs of picture cards (e.g. pictures of an apple,

orange, banana)
PROCEDURE:
Place one copy of each picture on the table or flat
Matches Pictures surface. Give the child the other pictures arranged in random
order. Demonstrate a matching response (e.g. picture on an
apple with another apple) and then return the pictures to the
child and say. "Put each picture on the on that is just like it"
Credit if the child match all the pictures correctly.

MATERIALS: 4 pairs of different shapes that are of the same

size and color.
PROCEDURE:
Show the child the shapes. Tell the child "Put together
Sort based on shapes the ones that are the same. "Afer the child sorts and groups
the shapes, point to the ones with the same shape and ask,
"Why did you put this together?" Credit if the child can group
the same shapes and say why they are the same (e.g. pareho
sila, pareho sila ng higus/shape, puro sila bilog)

MATERIALS: 4 pairs of the same shape that differ in size and

color.
Sorts object based on to PROCEDURE:
2 attributes (e.g. size and Show the child the shapes. Tell the child, "Put together
colors) the ones that are the same. Credit if the child can sort all the
shapes according to size and color.

MATERIALS: 4 pieces of graduates sized squares and 4 pieces of

graduated sized circles. PROCEDURE:
Show the
child first set of squares, spread out the random on a table or
flat surface. Say, "Here are 4 squares. Look, I can begin with the
Arranges objects smallest, then move to the next big one until reach the biggest
according to size from one. "Demonstrate how to arrange the squares. Then
smallest to biggest disarrange these and tell the child. "Now you start with the
smallest, put the next one and the big one until the last one.
Repeat this procedure using the circles without demonstrating.
Credit if the child arranges at least one set of shapes on correct
order from smallest to biggest. allow one trial for each set of
shapes.

MATERIAL: 6 papers of different colors

PROCEDURE:
Names 4 to 6 colors Ask the child, "What color is this?," Credit
if the child can name 4 to 6 colors correctly.

MATERIAL: papers and pencil/crayon

PROCEDURE:
Copies shapes Let the child copy a circle, triangle and square afer
demonstrating how each of these is done.
 Cognitive Material/Procedure Present Comments
1st Eval. 2nd Eval. 3rd Eval.
Names 3 animal or Credit if the child can name 3 animals and vegetables.
vegetables when asked

States what common Credit if he can state the use or function of at least 2
household items are
household items like a bed and a drinking glass.
used

MATERIALS: Sample 4 to 6 pieces puzzles

Can assemble simple PROCEDURE: Allow the child
puzzles to solve the puzzle in 2 minutes. Proceed to the next item afer
2 minutes.

Demonstrate an
understanding or
opposites by completing Credit if the child can give an opposite word
a statement (e.g. Ang
aso ay malaki, ang daga
ay _____?)

PROCEDURE:
Sit across the child and say "Show me your lef
Points to lef and right hand". Do the same thing for the following: right hand, lef
side of body food, right knee, lef shoulder, right eye, right knee, lef leg.
Credit if the child can correctly point out the lef and right side
on at least 5 body parts as requested

MATERIALS: 2 picture cards depicting activities that have

Can state what is silly or something silly or wrong with them.
wrong with pictures (e.g. PROCEDURE:
Ano ang mali sa Show the pictured scene to the child one at a
larawang ito?) time and ask, "What is wrong with the pictures?" Credit if the
child correctly identifies what made the picture incorrect

MATERIALS: 2 sets of alphabets cards with upper and lower

case letters
PROCEDURE:
Matches upper case Randomly present 4 pairs of uper case letters. Have the child
letters, and matches match these. Do the same with 4 pairs of lower case letters.
lowercase letters.
Credit if the chils can match 4 pairs, regardless of whether
these are upper and lower case. Note: The child does not have
to know names of the letters.

TOTAL SCORE

Socio-Emotional Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.
Enjoys watching
activities or nearby Parental report will suffice
people or animals

Friendly with strangers

but initially may show Parental report will suffice
slight anxiety or shyness

Plays alone but likes to

be near familiar adults or Parental report will suffice
brothers and sisters

Laughs or squeals aloud

Parental report will suffice
in play
Plays a peek-a-boo Parental report will suffice
(bulaga)

Rolls back interactively Parental report will suffice

with caregiver/examiner

Hugs or cuddles toys Parental report will suffice

Demonstrate respect for

elders using terms like Parental report will suffice
"po" and "opo"

Share toys with others Parental report will suffice

Imitates adult activities Parental report will suffice

(e.g. cooking, washing )

Identifies feeling in Credit if the child can tell when the caregiver is feeling happy,
others sad, worried, etc. Parental report will suffice

Appropriately uses
cultural gestures of
greeting without much Parental report will suffice
prompting (e.g. mano,
bless, kiss, etc. )

Comforts
playmates/sibling in Parental report will suffice
distress

Credit if the child tris to solve problem instead of crying when

Persists when faced with something stands in the way of what he wants (e.g. fastening
a problem or obstacle to box of his treasures with a string if the lid no longer closes)
his wants
Parental repaort will suffice

Socio-Emotional Material/Procedure Present Comments

1st Eval. 2nd Eval. 3rd Eval.

Helps with family chores

(e.g. wiping tables, Parental report will suffice
watering plants, etc.)

Curious about Credit if the child asks questions about things around him but
environment but knows knows when he is being "makulit" about the topics.
when to stop asking Parental
question of adults report will suffice

Wait for his turn Parental report will suffice

Ask permission to play

with toy being used by Parental report will suffice
another

Credit if the child tries to hold on to what is his when someone

Depends possessions tries to grab this from him.
with determination Parental report will suffice

Plays organized group

games fairly (e.g. does Parental report will suffice
not cheat to win)
 Can talk about complex
feelings (e.g. anger, Parental report will suffice
sadness worry( he
experiences

Honors a simple bargain

with caregiver (e.g. plays
outside only afer Parental report will suffice
cleaning, fixing his/her
room)

Watchers responsibly
over younger Parental report will suffice
siblings/family members

Corporates with adults

and peers in group Parental report will suffice
situations to minimized
quarrels and conflicts

TOTAL SCORE

Name of Examiner: __________________________________________

Date administered: __________________________________________
Place where tests is administered: _____________________________

To the examiner:
Write down your notes, descriptions and observations on the following points:

Child's background (ex. Behavior, health, etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Family environment (ex. Health of family members/family problems/economic conditions, etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Parents stimulating activities for the child (What are the activities/things that the parents do to help
stimulate the child's development?)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Home environment (ex. Facilities/Type of house.Household items/interaction/etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Others:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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