Gross Motor Domain Self - Help Domain Receptive Language Beginning Ending

Gross Motor Beginning Ending Self-Help Beginning Ending 1 Points to family member when asked to do so
Climbs on chair or elevated piece of furniture Feeds self with finger foods (e.g. biscuits, bread) Points to 5 body parts on himself when asked
1 1 2
like a bed without help. using fingers. to do so
Points to 5 named pictured objects when
2 Walks backwards 2 Feeds self using fingers with spillage. 3
asked to do so
3 Runs without tripping or falling. 3 Feeds self using spoon with spillage. Follows one-step instructions that include
4
Walks down stairs, 2 feet on each step, with simple prepositions (e.g., in, on, under, etc.)
4 4 Feeds self using fingers without spillage. Follows 2-step instructions that include simple
one hand held. 5
Walks upstairs holding handrail, 2 feet on 5 Feeds self using spoon without spillage. prepositions
5 each step. Eats without need for spoon feeding during any TOTAL SCORE
6
Walks upstairs with alternate feet without meal.
6 holding handrail. 7 Helps hold cup for drinking.
7
Walks downstairs with alternate feet without Expressive Language Domain
holding handrail. 8 Drinks from cup with spillage.
8 Moves body part as directed. 9 Drinks from cup unassisted. Expressive Language Beginning Ending
9 Jumps up 10 Gets drink for self unassisted. 1 Uses 5-20 recognizable words
10 Throws ball overhead with direction. 11 Pours from pitcher without spillage. 2 Uses pronouns (e.g. I, me, ako, akin)
11 Hops 1 to 3 steps on preferred foot. 12 Prepares own food/snack. Uses 2-3 words verb-noun combinations (e.g.
3
12 Jumps and turns. Prepares meals for younger siblings/ family hingi gatas)
13
members when no adult is around. 4 Names objects in pictures
Dances patterns/joins group movement
13 14 Participates when being dressed.
activities. Speaks in grammatically correct 2-3 word
5
15 Pulls down gartered short pants. sentences
TOTAL SCORE Asks “what” questions
6
16 Removes sando.
7 Asks “who”' and “why” questions
Dresses without assistance except buttons and
17 Gives account of recent experiences (with
tying.
Dresses without assistance including buttons and 8 prompting) in order of occurrence using past
Fine Motor Domain 18
tying. tense
Informs the adult only after he has already
TOTAL SCORE
Fine Motor Beginning Ending 19 urinated (peed) or moved his bowels (pooped) in
his underpants.
Uses all five fingers to get food/toys placed Informs adult of need to urinate (pee) or move
1
on flat surface. 20 bowels (poop) so he can be brought to a
2 Picks up objects with thumb and index finger. designated place (e.g. comfort room) Cognitive Domain
Goes to the designated place to urinate (pee) or
3 Displays a definite hand preference. 21 move bowels (poop) but sometimes still does this Cognitive Beginning Ending
4 Puts small objects in/out of containers. in his underpants.
Goes to the designated place to urinate (pee) or 1 Looks at direction of fallen object
Holds crayon with all fingers of his hand
5 22 move bowels (poop) and never does this in his
making a fist(ex.palmar grasp) 2 Looks for partially hidden object
underpants anymore
6 Unscrews lid of container or unwraps food. Imitates behavior just seen a few minutes
23 Wipes/Cleans self after a bowel movement (poop) 3
earlier
7 Scribbles spontaneously. Participates when bathing (e.g. rubbing arms with
24 4 Offers object but will not release it
8 Scribbles vertical and horizontal lines. soap)
25 Washes and dries hands without any help 5 Looks for completely hidden object
9 Draws circle purposely.
Exhibits simple pretend play (feed, put doll to
Draws a human figure (head, eyes, trunk, 26 Washes face without any help 6
10 sleep)
arms, hands/fingers) 27 Bathes without any help 7 Matches objects
11 Draws a house using geometric forms. 8 Matches 2 – 3 colors
TOTAL SCORE
TOTAL SCORES Cognitive Beginning Ending

9 Matches pictures
Receptive Language Domain
10 Sorts based on shapes to stop asking questions from adults School: _____________________________
11
Sorts objects based on 2 attributes (e.g., 17 Waits for turn School Year: __________________
size and color) Asks permission to play with toy being used
Arranges objects according to size from 18
12 by another
smallest to biggest
19 Defends possessions with determination
13 Names 4 – 6 colors
Plays organized group games fairly (e.g.,
14 Copies shapes 20
does not cheat in order to win)
Names 3 animals or vegetables when Can talk about difficult feelings (e.g., anger,
15 21
asked sadness, worry) he experiences.
States what common household items are Honors a simple bargain with caregiver (e.g.,
16
used for 22 can play outside only after cleaning/fixing his
17 Can assemble simple puzzles room)
Demonstrates an understanding of Watches responsibly over younger
23
18 opposites by completing a statement (e.g., siblings/family members
Ang aso ay malaki, ang daga ay _____”) Cooperates with adults and peers in group
24
19 Points to left and right sides of body situations to minimize quarrels and conflicts
Can state what is silly or wrong with TOTAL SCORE
20 pictures (e.g. Ano ang mali sa larawang
ito?)
21 Matches upper and lower case letters

TOTAL SCORE Beginning Date:_________ Ending Date:_________

Socio-Emotional Domain DOMAINS

Raw Scaled Raw Scaled
Score Score Score Score
Social-Emotional Beginning Ending
Gross Motor
1
Enjoys watching activities of nearby people or LRN:
animals Fine Motor
2
Friendly with strangers but initially may show Name:
slight anxiety or shyness Self-help
3
Plays alone but likes to be near familiar adults Sex: Date of Birth:
or brothers and sisters Receptive Language
4 Laughs or squeals aloud in play Expressive Language Teacher: __________________________________
5 Plays peek-a-boo (bulaga)
Cognitive
6 Rolls ball interactively with caregiver/examiner
Socio-Emotional To the Parents:
7 Hugs or cuddles toys The Philippine Early Childhood Care and
Demonstrates respect for elders using terms Sum of Scaled Score Development Checklist (Form 2) contain knowledge,
8
like “po” and “opo”
skills, and attitudes of children 3 – 5.11 years old. This
9 Shares toys with others
Standard Score may be used as a guide in knowing your child and
Imitates adult activities (e.g., cooking,
10
washing) consequently give appropriate care and teaching to
Interpretation
11 Identifies feelings in others guide their growth and development.
Appropriately uses cultural gestures of
12 greeting without much prompting (e.g., mano,
bless, kiss,etc.)
13 Comforts playmates/siblings in distress TESSA DAHL V. CAMPOS JOEL F. CANENCIA
Persists when faced with a problem or Adviser School Head
14
obstacle to his wants
Republic of the Philippines
Social-Emotional Beginning Ending Department of Education
Helps with family chores (e.g., wiping tables, Region VII, Central Visayas
15
watering plants, etc.) Division of Carcar City
16 Curious about environment but knows when