Republic of the Philippines

Department of Education
DIVISION OF DAVAO CITY
SAN JUAN ELEMENTARY SCHOOL
MINTRADE DRIVE, BRGY. CENTRO, AGDAO, DAVAO CITY
Office of the School Principal
SJES SPED FORM 1.2

NAME:__________________________________________________Grade and Section: ______________

TEACHER:_______________________________________________________

PARENTS NAME & SIGNATURE: _____________________________________

Difficulty in Difficulty in Remembering or Concentrating Checklist

CHARACTERISTICS CHECK
IF OBSERVED
A. Physical and Motor Characteristics
1.Is slightly lighter in weight than most children of his/her own group
2.Is shorter in height than most children of his/her own age group
3.Walks with stooping shoulders
4.Walks with uncoordinated swaying of the arms
5. Tendency to trip or stumble over objects while walking
6. Tendency to drop objects and articles
7. Has difficulty in maintaining balance while jumping, hopping, and
skipping
8. Has difficulty in using scissors
9. Has difficulty in using knives for slicing, paring, and cutting
10. Finds difficulty in tying shoelaces, ribbons or sash
11. Is unable to hold pen or pencil correctly
12. Has difficulty in tracing circle, square and triangle
13.Has difficulty in drawing a circle
14. Has difficulty in drawing square
15. Has difficulty in drawing a triangle
16. Has difficulty in writing letters of the alphabet
17. Finds difficulty in writing numbers
18. Has the following physical deformities:
a. Slanted eyes with coordinated eye muscles
b. Protruding forehead
c. Large protruding tongue
d. Wide face

Address: Mintrade Drive, Brgy. Centro, Agdao, Davao City

Tel. No.: (02) 297-7577
E-mail: sanjuan.es@deped.gov.ph
 Republic of the Philippines
Department of Education
DIVISION OF DAVAO CITY
SAN JUAN ELEMENTARY SCHOOL
MINTRADE DRIVE, BRGY. CENTRO, AGDAO, DAVAO CITY
Office of the School Principal
e. Disproportionately short hands and fingers
f. Broad hands with fingers having square ends
g. Teeth that are pegshaped and chalky
h. Swollen eyelids and eyes that are half-shut
i. Short thick neck
j. Short thick legs
k. Large head
l. Disproportionately small head
m. Dry, course and scaly skin
B. Personal and Social Characteristics
1. Tendency to be alone most of the time
2. Easily cries
3. Tendency to get angry at a slight provocation
4. Lacks concern and attention to events and people around him
5. Talks and laughs in an unnecessarily loud voice
6. Tendency to over react to events and people around him
7. Does not care about the feelings of others
8. Does not laugh easily when confronted with funny situations
C. Learning Characteristics
1. Has short attention span
2. Has poor memory
3. Has difficulty in comprehending situations in communication
4. Is easily distracted around him/her
5. Has difficulty in finishing work that has been started
6. Perseverates or repeats unnecessary action
7. Has reversals in written work
8. Has difficulty in relating isolated facts into meaningful ideas
D. Spoken Language
1.Refuses to talk
2.Has the tendency to speak in words or phrases instead
3.Tendency to talk in sentences with grammatical errors
4.Has immature or improper vocabulary
5. Tendency to have articulation problems such as:

Address: Mintrade Drive, Brgy. Centro, Agdao, Davao City

Tel. No.: (02) 297-7577
E-mail: sanjuan.es@deped.gov.ph
 Republic of the Philippines
Department of Education
DIVISION OF DAVAO CITY
SAN JUAN ELEMENTARY SCHOOL
MINTRADE DRIVE, BRGY. CENTRO, AGDAO, DAVAO CITY
Office of the School Principal
a. omissions
b. substitutions
c. additions
d. distortions
6. Gropes for words to express himself
Reference: NTOT/ BLD-SID

Address: Mintrade Drive, Brgy. Centro, Agdao, Davao City

Tel. No.: (02) 297-7577
E-mail: sanjuan.es@deped.gov.ph