IE_PEDIA_BU

University of Santo Tomas

College of Rehabilitation Sciences
Department of Occupational Therapy

OCCUPATIONAL THERAPY PEDIATRIC INITIAL EVALUATION

Name of Patient: _ ___________________________________________Age / Sex: ____ __ Date of Birth: _______________________ _

Address: _______________________________________________Telephone No.: __________________________________
Diagnosis: __________________________________________________Rehab Doctor in-charge: _______________________________
Precautions:_________________________________________________ Date of Initial Evaluation______________________________

SUBJECTIVE:

CHIEF COMPLAINT OT ORDERS/ GOALS

Indicate order/s from the referring physician
Indicate specific goals from the caregiver

HISTORY OF PRESENT ILLNESS

Pt was born (Full / Pre / Post ) term via ( NSD / CS ) to a GP() ____ y/o mother
Prenatal History
 Indicate if mother had vices during the pregnancy; illnesses or problems encountered
 If pre-natal check ups were conducted
 If possible indicate activities of the mother during the pregnancy

Perinatal History
 Indicate if mode of delivery, hospital; were there complications
 APGAR score (if recalled); Birth weight
 Newborn screening test/s and results (if any)

Postnatal History
 When did the primary caregiver noticed signs or symptoms (indicate specific age)
 Note the general behavior of the client including the age when specific skills were achieved (e.g. self-help etc)
 What prompted them to consult a doctor? When was consult made? What was the diagnosis?
 Doctor’s orders
 Did the child receive any services prior to evaluation? (OT, SLP, PT, SPED, or any form of intervention). If he received OT
services, what were the past managements given?

Developmental Milestones based on Brigance Diagnostic Inventory of Development

Skills Age expected Age achieved

*Specify skills that are pertinent

Current Medications: (if any)

PERSONAL-SOCIAL CONTEXT
Pt is ___among ____sibling/s.
Primary caregiver: __________________
 Relationship with: Parents/Caregiver:
 Educational Level of parents / caregivers:
 Parent’s occupation / means of support:
 Attitude of family towards disability / therapy
Routines/Habits:

Time Activity

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Play preferences/opportunities:
 As observed by the caregiver
 If possible, subjective information from the patient/child

Educational History:
 Indicate if child is currently attending the school; contextualize (number of students, typical activities, subjects, etc.)

PHYSICAL CONTEXT (pertinent to condition)

( ) Home ( ) School ( ) Others: ________________________________________

 Describe the context (number of rooms; floors/ where does the child spend most of his time; where does he sleep etc)

OBJECTIVE:

EVALUATION OF OCCUPATIONAL PERFORMANCE

PLAY

Play activities initiated by pt / given by therapist:

 Indicate the activities given by the therapist and/or initiated by the child during the evaluation

RESPONSE TO PLAY ACTIVITIES / GENERAL BEHAVIOR: PLAY LEVEL according to PIAGET:

( ) absent / unresponsive / inattentive ( ) Sensorimotor
( ) hyperactive ( ) Practice with Reflexes
( ) passive / shy ( ) Coordination of Secondary Schemes
( ) crybaby ( ) Primary Circular Reaction
( ) irritable ( ) Tertiary Circular Reaction
( ) temper tantrums ( ) Secondary Circular Reaction
( ) cooperative / playful ( ) Beginning of Thought
( ) Preoperational
PLAY LEVEL According to PRATT: ( ) Concrete Operational
( ) exploratory ( ) Formal Operations
( ) symbolic
( ) games Remarks:
( ) constructive

Remarks:

SOCIAL PARTICIPATION

EYE CONTACT:
( ) meaningful ( ) fleeting ( ) inconsistent ( ) absent

RESPONSE TO NAME CALLING:

( ) STRANGER ANXIETY:
( ) SEPARATION ANXIETY:
LEVEL OF SOCIAL INTERACTION ACCORDING TO PARTEN
( ) unoccupied ( ) solitary ( ) onlooker ( ) parallel ( ) associative ( ) cooperative

Remarks:

SELF-HELP

Age- Age-
Occupation Description appropriat inappropri Level of Assistance
e ate
Eating/Feeding

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UBG

Dressing

LBG
Toileting
Bathing
Grooming/Hygiene

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (If pertinent)

Level of independence:
( ) age-appropriate dependence
( ) age-inappropriate dependence
( ) independent

EDUCATION

 Describe the age appropriate and relevant activities given to the child
 Describe the response of the child

SOCIOEMOTIONAL FUNCTIONS AND COMMUNICATION / INTERACTION SKILLS

WORK / PLAY BEHAVIORS

Behavior Grade (P, F.G) Remarks

Attention Span Type/demands of activity given:
Response:
Concentration Type/demands of activity given:
Response:
Impulse Control Type/demands of activity given:
Response:

Frustration Tolerance Type/demands of activity:

Response:

LANGUAGE-COMMUNICATION SKILLS
Speech level:

Indicates needs through:

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SENSORY / PERCEPTUAL / COGNITIVE SKILLS

Sensory Functions Stimulus Response +/- Cognitive skills Remarks

Threat Ability to follow
Visual Localization ____step
Tracking directions
Localization
Auditory Imitation
Tracking (motor/ verbal)
Memory
Perceptual Functions Stimulus Response
Body Scheme Common Objects
Stereognosis
R/L Discrimination Body Part
Motor Planning
Shape
SENSORY INTEGRATION
Size
SSBs / SIBs:
Color

Number

Alphabet

Positional
Other Cognitive
Skills

NEUROMUSCULAR FUNCTIONS AND MOTOR SKILLS

ROM (WFL/WNL/ hypermobile/LOM 2° to) PRIMITIVE REFLEXES:
( ) Moro ( ) Positive Supporting
Grade Right Left ( ) ATNR ( ) Palmar Grasp
( ) STNR ( ) Plantar Grasp
Upper Extremities
( ) TLR

( ) Integrated

Lower Extremities POSTURAL RESPONSES:

Reaction Prone Sitting Standing

Righting
Others
Protective
Front
Sideways
back
Equilibrium

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FUNCTIONAL MUSCLE TESTING

MUSCLE TONE
Hypertonic MUSCLE STRENGTH: UE / LE / Trunk
Hypotonic/
Normotonic (Modified Flaccid For UE: Indicate the functional activity used to test and the
Ashworth)
UE response of the child/client
For LE:
LE For Trunk:

TRUNK MUSCLE BULK: Note if there is atrophy or hypertrophy

OTHER PERTINENT FINDINGS:

 Indicate if client is using any ambulatory aids, assistive devices; augmentative communication devices; deformities

GROSS MOTOR SKILLS

Age- Age
Remarks
appro innapro GMS
priate priate (duration, level of assist, activity)
HEAD CONTROL
pull to sit
prone
sitting
TRUNK CONTROL
rolling over
prone on
elbows
prone on hands

sitting

PELVIC CONTROL
pelvic bridging
quadruped
kneeling
standing

TRANSITION/ MOBILITY PATTERNS

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Pattern Remarks Pattern Remarks
( ) prone to supine ( ) crawling/ creeping
( ) supine to prone ( ) kneeling to standing
( ) supine to sitting ( ) cruising
( ) sitting to kneeling ( ) walking

FINE MOTOR SKILLS

Skill present absent emerging Remarks (type of toy used, quality)

Hand ( ) preference
( ) dominance
( ) handedness
Voluntary RGCR
Grip strength
Pinch strength
Spherical
GPP
Cylindrical
Hook
Lateral
Tripod
FPP
Pad to pad
Tip to tip

Bilateral Coordination
Eye-Hand
Arm-Hand
Midline Crossing

In-hand Manipulation:
(/) Remarks (Activity and Response of the child)
Finger-to-palm translation
Palm-to-finger translation
Shifting
Simple rotation
Complex rotation

ADVANCED GROSS MOTOR SKILLS

Remarks Remarks
Skill Skill
(quality of movement, activity) (quality of movement, activity)
( ) Running ( ) Throwing
( ) Jumping ( ) Catching
( ) Hopping ( ) Kicking
( ) Stairs &
Climbing

PRE-WRITING / WRITING SKILLS PRE-CUTTING / CUTTING SKILLS

Skill Remarks Skill Remarks

( ) Imitative Scribble ( ) Random

( ) Spontaneous Line
Scribble
Line ( ) Cut
Curve
( )
Shape Shapes
Tracing
Letter ( ) Cut Pictures/
( ) Line Figures
Imitation Shape ( ) Mature Scissor
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Letter Grasp
Line ( ) Complex Cutting
( )
Shape
Copying
Letter

 See attachments for additional tests

Assessment:
STRENGTHS WEAKNESSES

Prognosis:

Problem List:

Prepared by: Noted by:

____________________________ ____________________________
Name of Student