NAME: DIAGNOSIS:

AGE: GENDER:

GROSS MOTOR SKILLS

SKILLS NA 0 25 50 75 90 100

1 On her stomach h/she can lift head up.

2 On her stomach h/she can lift head up 45.

3 On her stomach h/she can lift head up 90.

4 On her stomach h/she can do chest up with arm support.

5 H/She can sit head steady.

6 H/She can roll over.

7 H/She can bear some weight on her legs.

8 When h/she was pull to sit there is no head lag

9 H/She can sit without support.

10 H/She can make lion king.

11 H/She can crawl.

12 H/She can stand on her knees holding on.

13 H/She can stand on her knees alone.

14 H/She can walk on her knees.

15 H/She can stand holding on.

16 H/She can pull self to stand.

17 H/She can get to sitting.

18 H/She can stand momentarily.

19 H/She can walk holding on furniture.

20 H/She can stand alone well.

NOTE
NAME: DIAGNOSIS:
AGE: GENDER:

GROSS MOTOR SKILLS

SKILLS NA 0 25 50 75 90 100

21 H/She can stoop and recover.

22 H/She can walk well.

23 H/She can walk backward.

24 H/She can walk up steps.

25 H/She can kick ball forward.

26 H/She can throw ball overhead.

27 H/She can balance on one foot one second.

28 H/She can jump in place.

29 H/She can pedal tricycle.

30 H/She can do broad jump.

31 H/She can balance on one foot 5 seconds.

32 H/She can balance on one foot 10 seconds.

33 H/She can hop on one foot.

34

35

36

37

38

39

40

NOTE