Little Big Steps

PEDIATRIC THERAPY
32A France Street, Better Living Subdivision, Paranaque City
Tel. No. 541-7791 / 09558677650
Email littlebigstepspediatric@gmail.com

OCCUPATIONAL THERAPY ASSESSMENT

Child’s Name: School:

Date of test: Date of Birth: Age: Male Female
Educational Placement: Regular Ed. Special Ed. Inclusion
Evaluating Therapist: Physician’s Referral dated:

DIAGNOSES:
Onset Diagnosis

HISTORY/BACKGROUND INFORMATION:
Remarkable Unremarkable Comments
Family/Social History

Birth History:

Age of Onset:
Medical History:

Allergies:

Specialists Seen:

Diagnoses:

Physical Development:

Respiration/Cardiovascular
Status:
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Auditory:
Vision:
LITTLE BIG STEPS PEDIATRIC THERAPY CLINIC, INC.
 Medications:
Precautions:

Other Relevant Medical History:

Reason for referral: Fine motor Gross motor Self-help Sensory-motor Visual-motor
Writing Other/Chief Complaints:

Prior therapy: Currently receiving outside therapy at:

Currently receiving therapy through school system:
Other:
Primary means of communication: Verbal, language (s):
Non-verbal Pictures Gestures Other:
Testing Environment: Private Clinic Quiet environment Other:
Family member (s) present:

Behavioral observation during testing: Good attention span Limited attention span Cooperative
Impulsive Exhibited good effort Lacked effort Engages easily Difficulty engaging
Follows verbal directions Follows demonstrations Responds to redirection
Doesn’t follow directions Other:

EVALUATION TOOLS:
Family/Caregiver interview
Clinical Observation/non-standardized tasks
Standardized Assessment:

SENSORY PROCESSING SUMMARY:

Comments

Auditory: Over Responsive

Under Responsive
Passive
Under Responsive
Seeker

Visual: Over Responsive

Under Responsive
Passive
Under Responsive
Seeker

Tactile: Over Responsive The Tactile system is the largest sensory system of the body. Its
Under Responsive
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 Passive sensory receptors can be located on the skin, inside the mouth,
Under Responsive throat and digestive tract. The different tactile sensations are
Seeker vibration, light touch, deep pressure, temperature and pain.

Oral: Over Responsive

Under Responsive
Passive
Under Responsive
Seeker

Vestibular: Over Responsive The sensory receptors of the vestibular system are located in
Under Responsive the inner ear. It helps maintain our balance and prevents us
Passive from falling. The vestibular system plays a vital role in a child's
Under Responsive physical development. The system is stimulated when our head
Seeker position is changed. Spinning, swinging and looking upside down
provide intense vestibular input. Children who struggle to
process movement information from their vestibular systems
may also struggle with bilateral integration.
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 Proprioception: Over Responsive The proprioceptive sense provides feedback from our joints and
Under Responsive muscles regarding stretch and force, as well as body position
Passive and movement of our body through space. The proprioceptive
Under Responsive system is stimulated when we lift, pull and push weighted
Seeker objects. We feel the sensation on our joints and muscles when
we push joints together, such as when jumping, or pull joints
apart, such as climbing a ladder or hanging on monkey bars.
Intense proprioceptive input such as heavy work tasks, appear
to be calming and helps children to self-regulate.

Proprioception: Adequate grasp/release force Inadequate grasp/release force

Grades movements adequately Poor grading of movements Bumps into objects/is clumsy
Enjoys bouncing/crashing into objects Looks at hands during familiar tasks

Comments:

FINE MOTOR SKILLS:

Not applicable

Hand Dominance: Right Left Mixed Undetermined, not an age-appropriate skill

Upper extremity range of motion within functional limits:
Yes No, explain:
Muscle tone within normal limits: Yes No, explain:
Sitting Posture: Functional Slumps in chair Head on hand Legs wrapped around chair
Constantly shifting/fidgety Posturally insecure Sits on legs
Adaptive seating:

School-aged children should be able to sit with both feet flat on the floor with a 90 degree angle at the knees and
hips. This posture improves their attention and participation in task. Increased ability to maintain proper sitting
posture may be due to increased core muscle strength and stability.
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 Bilateral Coordination: stabilizes/assists with: Other hand Body
Stabilizes adequately Inconsistent stabilization Poor use of hands together Does not stabilize
Transfers objects Crosses midline Claps

Grasp of objects: Pincer Lateral Raking Swiping 5 pt 3 pt No grasp

Release of objects: Intact/Voluntary Impaired No release
Reach for objects: Accurate Over/undershoots No reach

In-hand manipulation: Intact

Difficulty with: Shift P-F Translation F-P Translation Rotation

Motor Planning: Initiates activities Poor approach to tasks Difficulty learning new motor tasks
Imitates body postures:
Comments:

Notes:

Crossing the Midline: Crossing the midline happens when your child moves their hand or foot across the
midline to work on the opposite side of their body. Crossing the midline is important
because when children can do this activity, they are using both sides of their brain to
coordinate smooth, controlled, complex movement. It is important to combine
movement patterns that cross the body for daily tasks such as reading, writing and tying
shoelaces.

Bilateral Integration: Consistency in bilateral coordination is important. Being able to coordinate movements
on both sides of the body, whether performing fine motor or gross motor tasks, means
that neural pathways are working together on both sides of the child's brain; that both
sides are able to communicate well in order to gauge the amount of precision, strength
or force needed to perform a task.
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 Praxis: Praxis is the ability by which we figure out how to use our hands and body in skilled tasks
such as eating with utensils, play with toys, using a crayon, building with blocks, dressing
ourselves, and engaging in many daily activities. Praxis involves spontaneously
sequencing and organizing movements in a coordinated manner to complete unfamiliar
motor tasks.

Dexterity: Dexterity is the ability to use your hands skillfully, fluently, quickly, and easily.

Cutting Skills: Regular scissors Adapted scissors No prior experience

Hand used: Right Left Mixed Both hands on scissors simultaneously
Grasps adequately Stabilizes adequately Needs hand positioned Poor stabilization
Difficulty placing scissors on paper Difficulty with continuous cutting
Snips paper Unable to snip Cuts across paper Unable to cut across paper

Cuts straight line on line Cuts straight line within of line Unable
Cuts curved line on line Cuts curved line within of line Unable
Cuts simple shape on line Cuts simple shape within of line Unable
Cuts complex shape on line Cuts complex shape within of Unable
line
Comments:

Handwriting Y I N Comments
Not applicable
Letters formed Bottom to top formation Has not learned all letters
correctly Misforms
Letter size adequate Too large
Too small
Letters oriented to Letters off line Needs visual cues (i.e. bold lines,
lines adequately "Go under" letters boxes)
(g, j, p, q, y) off line
"Tall" letters
(b,d,f,h,k,l) off line
Letter spacing is Under spaced Uses finger to space
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adequate Over spaced

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 Word spacing is Under spaced
adequate Over spaced
Margins are Doesn’t start at left Dislikes writing or does not want to
adequate margin write
Inadequate space at Poor attention to writing
end of line
Speed of writing is Takes longer to complete Dislikes writing/does not want to
adequate writing write
Rushes through writing Poor attention to writing
Quality of writing is Illegible Dependent on attention to task
adequate Dependent on speed of tasks
Key: Y = Yes I = Inconsistent N = No

Comments:

GROSS MOTOR SKILLS:

Not applicable Refer to Physical Therapy report

Ball skills: Throws ball Unable to throw Catches ball with hands Catches ball against body
Kicks moving ball Kicks stationary ball Anticipates ball Unable to catch Unable to kick

Stairs: Walks up stairs Independently supervised with assistance crawls holds rails
unable
Alternates feet going upstairs two feet per stair going upstairs Did not assess
Alternates feet going downstairs two feet per stair going downstairs Did not assess

Muscle tone within normal limits: Yes No, explain:

Other: Able to hop Able to stand on one foot Able to jump in place
Unable to hop Unable to jump
Comments:

VISUAL PERCEPTUAL SKILLS:

Not applicable
Visual tracking:
Intact Difficulty tracking across midline Difficulty tracking vertically Unable
Visual regard: Intact Needs cues to look at task Adequate eye contact Poor eye contact
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 Visual discrimination – Colors: Intact Not assessed
Matches: Red Blue Green Yellow Emerging Unable
Points to when requested: Red Blue Green Yellow Emerging Unable
Names when pointed to: Red Blue Green Yellow Emerging Unable
Visual discrimination – Shapes: Intact Not assessed
Matches: Diamond Rectangle Triangle Square Circle Emerging Unable
Points to upon request: Diamond Rectangle Triangle Square Circle Emerging Unable
Names when pointed to: Diamond Rectangle Triangle Square Emerging Unable
Circle
Visual Spatial Relations: Intact Not Assessed
Distinguishes left from right on self: Yes No
Understands basic directional terms: Yes Emerging No
Comments:
Able to build: Pyramid Stairs Wall Bridge Train Block tower of blocks
Unable
Completes: Interlocking puzzle Inset puzzle Three shape form board Unable
Body Concept/Body Awareness: Intact Not Assessed
Points to when requested: Mouth Eyes Nose Ears Tongue Head Arms
Hands Fingers Thumb Elbow Legs Knees Feet Stomach Back Unable
Names when pointed to: Mouth Eyes Nose Ears Ton gue Head Arms
Hands Fingers Stomach Back
Thumb Elbow Legs Knees Feet Unable
ue Head A
Draw a person includes: Mouth Eyes Nose Ears Tong rms
Stomach Back
Hands Fingers Thumb Elbow Legs Knees Feet Unable
Figure Ground: Intact Not Assessed
Completes a hidden picture: Independently With minimal assist With maximal assist Unable
Completes a word find: Independently With minimal assist With maximal assist Unable
Comments:

VISUAL MOTOR SKILLS: Intact

Pencil Grasp: Uses right hand Uses left hand Switches hands Uses pencil grasp
Holds pencil near tip Holds pencil near distal end Constantly adjusting grasp Hooked
wrist Dynamic tripod Lateral tripod Quadruped Static tripod Thumb wrap
Thumb tuck Digital pronate (artist’s) Palmar supinate (dagger) Radial cross palmar
Other:
Pencil Pressure: Appropriate Heavy Light

Pre-Writing Strokes T I C Comments

Vertical Line
Horizontal Line Poor adjustment of stroke to line Does not fill entire area
Circle Poor adjustment of stroke to line Does not fill entire area
“+” sign
Square
Diagonal Line
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“X” sign
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LITTLE BIG STEPS PEDIATRIC THERAPY CLINIC, INC.

 Triangle
Pre-Writing Strokes T I C Comments
Diamond:
First/Last name
Uppercase Letters
Lowercase Letters
Numbers
Others
Key: T = Traces I = Imitates C = Copies

PLAY:
Preferred Activities / Toys:

Avoided or Disliked Activities / Toys:

Quality of Play:

Play Behaviors:

SELF HELP SKILLS: Not applicable

Independent Assisted Comments
Spoon
Fork
Knife
Drink from Cup
Straw
Bottle
Toothbrush
Handwashing
Toileting Wears pull-ups Wears diapers
Indicates when wet: Verbally
Non-verbally
Does not indicate

Intitiates going to the bathroom: Verbally

Non-verbally
Does not initiate
Shirt
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Pants
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LITTLE BIG STEPS PEDIATRIC THERAPY CLINIC, INC.
 Socks
Shoes
Zip
Unzip
Button
Unbutton
Snaps
Buckle/Belt
Shoetying

STRENGTHS:

PERFORMANCE IMPAIRMENTS:

RECOMMENDATIONS:

The following Occupational Therapy services are recommended:

Direct services at times/week for months
Other:

Occupational therapy will address the following areas:

Fine-motor skills Visual perceptual skills Visual-motor skills Self-help skills
Other:
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 PLANNED INTERVENTIONS:

OCCUPATIONAL THERAPY GOALS:

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 Signatures: Date:
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