Name: ______________________________ Nickname: ________________ 4. Feeds self using fingers with spillage.

EXPRESSIVE LANGUAGE DOMAIN

Date of Birth:_________________________ Age: ________ 5. Fedds self using fingers without spillage. EXPRESSIVE LANGUAGE PRESENT COMMENTS
Sex: _______ 6. Eats without need for spoonfeeding during 1. Uses 5-20 recognizable words.
any meal. 2. Uses pronouns (e.g. I, me, ako, akin)
GROSS MOTOR DOMAIN 7. Helps hold cup for drinking. 3. Uses 2-3 words verb-noun combinations (e.g.
GROSS MOTOR PRESENT COMMENTS 8. Drinks from with spillage. hingi gatas).
1. Climbs on chair or other elevated piece of 9. Drinks from cup unassisted. 4. Names objects in pictures.
furniture like a bed without help. 10. Gets drink for self unassisted. 5. Speaks in grammatically correct 2-3 word
2. Walks backwards 11. Pours from pitcher without spillage. sentences.
3. Runs without tripping or falling. 12. Prepares own food/snack. 6. Asks “what” questions.
13. Prepares meals for younger siblings/family 7. Aks “who” questions.
4. Walks down stairs, 2 feet on each step, with
members when no adults is around. 8. Gives account of recent experiences (with
one held.
14. Participates when being dressed(e.g., raises prompting) in order of occurence using past
5. Walks upstairs holding handrail, 2 feet on tense.
arms or lifts leg).
each step.
15. Pulls down gartered short pants. TOTAL SCORE
6. Walks upstairs with alternate feet without
16. Redmoves sando. COGNITIVE DOMAIN
holding handrail.
17. Dresses without assistance including COGNITIVE PRESENT COMMENTS
7. Walks downstairs with alternate feet without
buttons and tying. 1. Looks at direction of fallen object.
holding handrail.
18. Dresses without assistance except for 2. Looks dor partially hidden object.
8. Moves body parts as directed.
buttons and tying. 3. Immitates behavior just seen a few minutes
9. Jumps up. 19. Informs the adult only after he has already earlier.
10. Throws ball overhead with direction. urinated (peed) or moved his bowels 4. Offers object but will not release it.
11. Hops 1-3 steps on preffered foot. (poohed) in his underpants. 5. Looks for completely hidden object.
20. Informs adult of need to urinate (pee) or 6. Exhibits simple pretend play (feed, put doll to
12. Jump and turn.
moved bowels (pooh-pooh) so he can be slep).
13 Dances patterns/joins group movement brought to designated place (e.g. comfort 7. Matches objects.
activities. room). 8. Matches 2-3 colors.
TOTAL SCORE 21. Goes to the designated place to urinate 9. Matches pictures.
FINE MOTOR DOMAIN (pee) or move bowels (pooh) and never 10 Sorts based on shapes.
FINE MOTOR PRESENT COMMENTS does this is his underpants anymore> .
1. Uses 5 fingers to get food/toys placed on flat 22. Goes to the designated place to urinate 11 Sorts objects based on 2 attributes (e.g. size
surface. (pee) or move bowels (pooh) and never . and color).
2. Picks up objects with thumb and index does does this is his underpants anymore. 12 Arranges objects according to size from
finger. 23. Wipes/clean self after a bowel movement.. . smallest to biggest>
3. Display a definite hand preference. 24. Participates when bathing (e.g. Rubbing 13 Names 4-6 colors.
4. Puts small objects in/out of containers. with soap). .
5. Holds crayon with all the fingers of his hand 25. Washes and dries hands without any help. 14 Copies shapes.
making a fist(i.e, palmar grasp) 26. Washes face without any help. .
6. Unscrews lid of container or unwraps food. 27. Bathes withou any help. 15 Names 3 animals or vegetables when asked.
7. Scribbles spontaneously. TOTAL SCORE .
8. Scribbles vertical and horizontal. RECEPTIVE LANGUAGE 16 States what common household item are
9. Draws circle purposely. RECEPTIVE LANGUAGE PRESENT COMMENTS . used for.
10. Draws a human figure( head, eyes, trunk 1. Points to family members when asked to 17 Can assemble simple puzzles.
arms, hand /fingers). do so. .
11. Draws a house using geometric forms. 2. Points to 5 body parts on himself when 18 Demonstrates an understanding of opposites
TOTAL SCORE asked to do so. . by completing a statement (e.g. Ang aso ay
SELP-HELP DOMAIN 3. Points 5 named picturd objects when asked malaki. Ang daga ay maliit.)
SELP-HELP PRESENT COMMENTS to do so. 19 Points to left and right side of the body.
1. Feeds self with finger food(e.g, biscuits, 4. Follws one-step instructions that include .
bread) using fingers. simple prepositions (e.g. in, on, under, etc.) 20 Can state what is silly on wrong with pictures
2. Feeds self using spoon with spillage 5. Follows 2-step instructions that include . (e.g. Ano ang mali sa larawang ito?)
3. Feeds self using spoon without spillage. simple preposition. 21 Matches upper and lower case letters.
TOTAL SCORE .
 TOTAL SCORE
SOCIAL EMOTIONAL DOMAIN
SOCIAL-EMOTIONAL PRESENT COOMENTS
1. Enjoys watching activities of nearby people or
animals.
2. Friendly with strangers but initially may show
slight anxiety or shyness.
3. Plays alone but likes to be near familliar adults
or brothers and sisters.
4. Laughs or squels aloud in play. Republic of the Philippines
5. Plays peek-a-boo (bulaga). Department of Education
6. Rolls ball interactively with Region IV – MIMAROPA
caregiver/examiner. LUBANG INTEGRATED SCHOOL
7. Hugs or cuddles toys.
Lubang
8. Demonstrates respect for elders using terms
like “po” and “opo”.
9. Shares toys with others. JUNE OCTOBER MARCH
10
.
Immitates adult activities (e.g. cooking,
washing)
Philippine Early Childhood
11 Identifies feelings in others. Sum of Development Checklist
. Scaled Scores
12 Appropriately uses cultural gestures of
Form 2
. greeting without much prompting (e.g. mano, (3.0-5.11 years old)
bless, kiss, etc.) Standard
13 Comforts playmates/siblings in distress. Score
.
14 Persists when faced with problem or obstacle
. to his wants.
Interpretation
15 Helps with family chores( e.g. wiping tables, of Standard
. watering plants, etc.) Score
16 Curious about environment but knows when PARENT’S/GUARDIAN NAME AND SIGNATURE
. to stop asking questions of adults.
17 Waits for turn.
. JUNE
18 Asks permission to play with toy being used by OCTOBER
. another. MARCH
19 Defends possessions with determination.
.
20 Plays organized group games fairly (e.g. does
. not cheat in order to win).
21 Can talk about difficult feelings (e.g. anger,
. sadness, worry) he experiences.
22 Honors a simple bargain with caregiver (e.g.
. can play outside only after cleaning/fixing his Child’s Name:
room). Birthdate: Age: S.Y: 2013-2014
23 Watches responsibly over younger
. siblings/family members. LRN: Sex: Male
24 Cooperates with adults and peers in group
. situations to minimize quarrels and conflicts.
TOTAL SCORE
ERMELITA T. VILLAR VANESSA V. NAZARENO
ES PRINCIPAL II TEACHER