Details

This information is optional. It is not stored and used only for inclusion on the assessment result printout.

Child's First Name:

Child's Surname:

Age:

 

1. Pencil Skills

Does your child:

Hold their pencil awkwardly so that control is difficult or press too hard or lightly on the page?

Yes No

Find it difficult to perform drawing/colouring/writing for long periods (pain/tired)?

Yes No

Perform tasks slower than their peers or with less refined skill/neatness for their age?

Yes No

Fail to use space on the page appropriately (e.g. start at right not left, and starts new lines inappropriately)?

Yes No

Have trouble working out HOW to draw (e.g. asks adults to draw for them) or WHAT to write?

Yes No

2. Scissor Skills

Does your child:

Hold scissors and/or paper awkwardly when cutting or avoid cutting activities?

Yes No

Have difficulty turning the paper when cutting (so looks clumsy/awkward using 2 hands)?

Yes No

Find it difficult to cut through different cutting textures (eg cardboard, paper)?

Yes No

'Snip' the paper rather than 'cut' along the line or does the outcome look choppy?

Yes No

Struggle to stay on the line when cutting, especially for curved or geometric shapes?

Yes No

3. Manipulation and Utensil Use

Does your child:

Use their whole hand rather than fingertips to hold/use small objects (eg Lego, blocks & puzzles)?

Yes No

Find it difficult to hold and control cutlery (when cutting food)?

Yes No

Need prompting to look at the details when completing a worksheet or copying a picture?

Yes No

Lack consistent use of one dominant hand for object manipulation or task performance?

Yes No

Find it difficult to open lunch boxes/bags/pencil cases or to do up buttons/zips/laces?

Yes No

4. Balance and Coordination

Does your child:

Find it difficult to maintain static (still) positions for an extended period of time, (so that they frequently move: e.g. rolling on the floor or changing sitting positions)?

Yes No

Seem careless, clumsy or rougher than intended in play or appear slow to react (e.g. misses a ball thrown at them)?

Yes No

Need to watch peers before attempting the task (to learn how to do it)?

Yes No

Have difficulty riding a bike/scooter, walking a balance beam or climbing an A-Frame?

Yes No

Take longer than typical to master new skill or forgets how if not practiced regularly?

Yes No

5. Strength and Endurance

Does your child:

Tire quickly or have a slumped posture (at the table, on the matt, or in play)?

Yes No

Look like they are putting in more effort than typical to physical play or positions?

Yes No

Avoid physical play (eg falling frequently, being silly or refusing when tasks are difficult)?

Yes No

Only participate in physical play for a short period of time or only in short spurts?

Yes No

Look clumsy, lack co-ordination, trips frequently or seem overly cautious on the playground?

Yes No

6. Skill Performance and Participation

Does your child:

Find it difficult to refine/modify skill performance (e.g. throwing/kicking longer to reach target)?

Yes No

Avoid bat and/or ball skills (or look awkward and stiff in movements)?

Yes No

Display limited tolerance/persistence for learning new skills?

Yes No

Require step-by-step instructions and explicit modelling of movements to succeed?

Yes No

Find it hard to combine 2 movements together with control and consistency (e.g. step and throw)?

Yes No

7. Self Care and Behaviour

Does your child:

Require extensive help to fall asleep (eg patting/adult lying with them)?

Yes No

Take a long time to calm after becoming 'wound up' or distressed?

Yes No

Display excessive dislike of food textures/temp./teeth cleaning/hair brushing?

Yes No

Find it difficult to tolerate certain clothing articles/fabrics/tags/shoes?

Yes No

Have trouble tolerating changes in routine, so that they seek routine and/or constant reassurance of routine (or need advanced warning of change)?

Yes No

8. Attention and Activity Levels

Does your child:

Seek out movement so much it interferes with tasks (eg spins, fidgets, can't sit still)?

Yes No

Seem lazy/lethargic/day-dreamy/hard to motivate/in their own world or are constantly on-the-go, find it hard to wait/are physically active?

Yes No

Require constant reminders to stay on task or flit between activities without completing them?

Yes No

Avoid large groups of people (playground, classroom, parties) / prefer solitary play?

Yes No

Get 'wound up' in busy (noisy) environments (eg shopping centres, kids parties)?

Yes No

9. Learning

Does your child:

Have difficulty beginning a task and/or sustaining performance independently?

Yes No

Have difficulty problem solving independently when confronted by a challenge (may give up easily, get frustrated or refuse)?

Yes No

Require tasks to be broken down and demonstrated one step at a time?

Yes No

Have difficulty transferring a learnt skill from task to task (eg different variations of addition)?

Yes No

Find it difficult to retain learnt skills if not continually practiced?

Yes No

10. Organisation at school

Does your child:

Have difficulty determining and collecting materials for a task (eg calculator, eraser AND maths book for Maths lesson)?

Yes No

Packing/unpacking their school bag or knowing how to pack away a mess?

Yes No

Lose track of personal items (eg sweater, hat, lunch box)?

Yes No

Fail to correctly generate and sequence the steps in a task (eg morning routine)?

Yes No

Have difficulty following day-to-day routines that are well known to them (replace reader, hand up diary and then put bag away)?

Yes No

11. Organisation at Home

Does your child:

Show poor task persistence (e.g. gets very frustrated when can't complete a task)?

Yes No

Have difficulty starting and continuing independent play with a broad range of activities (constantly seeking adult guidance)?

Yes No

Have difficulty locating familiar items in the environment (e.g. shoes, pyjamas, favourite toys)?

Yes No

Have difficulty completing multiple verbal instructions independently?

Yes No

Have difficulty remembering everyday requirements (e.g. making bed or cleaning teeth before bed)?

Yes No

12. Daily Skills

Does your child:

Have difficulty correctly sequencing task performance (e.g. underwear first when dressing)?

Yes No

Need more help physically cleaning teeth/brushing hair than age appropriate?

Yes No

Get easily distracted when performing routine activities so not completed?

Yes No

Take a long time to initiate or perform a task?

Yes No

Look like they 'just can't get it together' (disorganised thinking)?

Yes No