CHECKLIST FOR REFERRAL TO:

OCCUPATIONAL THERAPY PHYSICAL THERAPY

Use of this form provides notice to therapists of concerns with fine and/or gross motor skills.
The therapists will determine the need for full evaluation.

Student's Name: Birth Date:

School: Grade:

Referred by: Date:

Please check items below that interfere with the student's educational performance.

FINE MOTOR
Hand dominance inconsistent Avoids crossing midline of body with arms Difficulty manipulating small objects
Weak grasp or pinch Tremors or shakiness observed during hand movements

WRITTEN WORK
Pencil grasp awkward Incorrect placement of letters within writing lines Pencil pressure too light
Pencil pressure too hard Difficulty copying correctly from books or board Breaks pencil lead
Tires easily when writing Does not stabilize paper with other hand Slow rate of writing
Writing labored and slow Inadequate spacing between letters and words Poor legibility of written work
Difficulty aligning math problems on paper correctly Forms letters from bottom to top
Difficulty recalling letter/number formation, reverses letters/numbers Changes grasp while writing

SCISSORS SKILLS
Does not position scissors in hand correctly Difficulty opening scissor blades
Difficulty coordinating both hands to cut and turn paper Inaccurate cutting on lines of shapes/pictures

VISUAL PERCEPTION
Difficulty doing puzzles Difficulty discriminating: Colors Shapes Sizes
Difficulty locating relevant visual information from background

SENSORY PROCESSING
Easily distracted by: Auditory Stimuli Visual Stimuli Difficulty sitting still
Overly sensitive to physical touch Seeks out excessive amounts of movements
Avoids touching mess media (glue, fingerpaint,Playdoh, etc) Overly sensitive to movement activities, gets dizzy

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 CHECKLIST FOR REFERRAL TO:
OCCUPATIONAL THERAPY PHYSICAL THERAPY

Student's Name: Date:

SELF CARE
Difficulty managing fasteners: Snaps Zippers Buttons Buckles
Does not tie shoes
Difficulty with dressing tasks, putting on/taking off: Coat Shoes/Boots
Difficulty with toileting needs: Managing Clothing
Difficulty with eating: Using Utensils Opening Packages Carrying Tray
Difficulty washing/drying hands

ORGANIZATION
Difficulty working independently
Disorganization of work space/materials

GROSS MOTOR
Fearful of movement activities Avoids recess or gym activities/equipment
Appears clumsy Shuffles feet when walking
Decreased safety awareness during movement activities Walks or runs with legs wide apart
Decreased arm swing when walking or running Muscles appear weak/loose
Muscles appear tight/rigid Walks on toes
Poor posture when standing with swayed back and/or rounded shoulders
Poor posture when sitting - slouches in chair, holds head up with arm and hand
Low endurance/fatigues easily during movement activities
Difficulty moving down to/or up from the floor alone Difficulty rolling/maneuvering wheelchair
Difficulty entering or exiting through doors alone
Decreased balance while: Sitting Standing
Incoordination when: Jumping Hopping Skipping Running

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