NAME: _________________________________________AGE: Speech: Age Appropriate _____ Remarks: _____ Spoken

______ Words
Dev’ ped: _______________________ Last Assessment: Sit Still Focus: ______________
____________ ______ Reading ______ Language
OT Center: _______Mathematics
________________________________________________ OTHERS:
ST Center: Use of Gestures Fidgetiness
________________________________________________ Gibbering Problems Playing Quietly
Case/Diagnosis: (fear/shock/rapidly/unintelligently)
____________________________________________ Eye Contact Unfinished Tasks
Previous School: Responding to names Leaves their seat despite
____________________________________________ being told not to do so
Level: ________ Program: Imitating others Talks excessively
_________________________________
smiling Follows instructions
Parent’s Contact No.
________________________________________ Loses things
KINDER: ACADEMICS Listening Skills Easily distracted
POINT LABEL (IDENTIFY) Trouble Staying Forgetful in activities
(RECOGNITION)
Alphabets
Numbers
Colors
Shapes NAME: _________________________________________AGE:
Fine Motor ______
Skills Dev’ ped: _______________________ Last Assessment:
Speech: Age Appropriate _____ Remarks: _____ Spoken ____________
Words OT Center:
Sit Still Focus: ______________ ________________________________________________
______ Reading ______ Language
ST Center:
_______Mathematics ________________________________________________
OTHERS: Case/Diagnosis:
Use of Gestures Fidgetiness ____________________________________________
Previous School:
Gibbering Problems Playing Quietly
____________________________________________
(fear/shock/rapidly/unintelligently)
Level: ________ Program:
Eye Contact Unfinished Tasks
_________________________________
Responding to names Leaves their seat despite Parent’s Contact No.
being told not to do so
________________________________________
Imitating others Talks excessively KINDER: ACADEMICS
smiling Follows instructions POINT LABEL (IDENTIFY)
Loses things (RECOGNITION)
Listening Skills Easily distracted Alphabets
Trouble Staying Forgetful in activities Numbers
Colors
NAME: _________________________________________AGE: Shapes
______ Fine Motor
Dev’ ped: _______________________ Last Assessment: Skills
____________ Speech: Age Appropriate _____ Remarks: _____ Spoken
OT Center: Words
________________________________________________ Sit Still Focus: ______________
ST Center: ______ Reading ______ Language
________________________________________________ _______Mathematics
Case/Diagnosis: OTHERS:
____________________________________________ Use of Gestures Fidgetiness
Previous School: Gibbering Problems Playing Quietly
____________________________________________ (fear/shock/rapidly/unintelligently)
Level: ________ Program: Eye Contact Unfinished Tasks
_________________________________ Responding to names Leaves their seat despite
Parent’s Contact No. being told not to do so
________________________________________ Imitating others Talks excessively
KINDER: ACADEMICS
smiling Follows instructions
POINT LABEL (IDENTIFY)
(RECOGNITION) Loses things
Alphabets Listening Skills Easily distracted
Numbers Trouble Staying Forgetful in activities
Colors
Shapes NAME: _________________________________________AGE:
Fine Motor ______
Skills
Dev’ ped: _______________________ Last Assessment:
____________
OT Center:
________________________________________________
ST Center:
________________________________________________
Case/Diagnosis:
____________________________________________
Previous School:
____________________________________________
Level: ________ Program:
_________________________________
Parent’s Contact No.
________________________________________
KINDER: ACADEMICS
POINT LABEL (IDENTIFY)
(RECOGNITION)
Alphabets
Numbers
Colors
Shapes
Fine Motor
Skills
Speech: Age Appropriate _____ Remarks: _____ Spoken
Words
Sit Still Focus: ______________
______ Reading ______ Language
_______Mathematics
OTHERS:
Use of Gestures Fidgetiness
Gibbering Problems Playing Quietly
(fear/shock/rapidly/unintelligently)
Eye Contact Unfinished Tasks
Responding to names Leaves their seat despite
being told not to do so
Imitating others Talks excessively
smiling Follows instructions
Loses things
Listening Skills Easily distracted
Trouble Staying Forgetful in activities