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. Foundation Mobility Skills

Does your child:

Have difficulty rolling over freely in all directions?

Yes No

Have difficulty crawling on hands and knees?

Yes No

Have difficulty getting up off the floor from lying down without help?

Yes No

Have difficulty taking 5 steps forward without support?

Yes No

Look unsteady / awkward when walking compared to friends of similar age?

Yes No

2. Complex Mobility Skills

Does your child have difficulty:

Lowering themselves from standing to pick up a toy and return to standing without losing balance?

Yes No

Playing for an extended period in the squatted position?

Yes No

Going up and down stairs 2 feet per step whilst holding onto rail?

Yes No

Jumping down a step with one foot leading?

Yes No

Riding a push car or trike, pushing with two feet on the ground?

Yes No

3. Ball skills

Does your child have difficulty:

Rolling a ball along the ground to a partner?

Yes No

Kicking a stationary ball with accuracy?

Yes No

Kicking a stationary ball without stumbling?

Yes No

Throwing a large ball (without accuracy at 12 months, with accuracy from 18 months)?

Yes No

Throwing a tennis ball?

Yes No

4. Standing on one leg

Does your child have difficulty:

Standing with hands free for longer than 5 seconds?

Yes No

Standing independently while holding a toy?

Yes No

Putting their leg into their pant leg when you are dressing them in standing?

Yes No

Standing on one leg (for 1 second)?

Yes No

Stepping over a toy without losing balance?

Yes No

5. Clumsiness/awkwardness

Does your child:

Have a clumsy manner/lack coordination compared with peers of similar age?

Yes No

Fall frequently?

Yes No

Not attempt to put their arms out for protection when falling?

Yes No

Have difficulty keeping their balance while playing?

Yes No

Have difficulty walking about without bumping into objects?

Yes No

6. Impulsiveness

Does your child:

Have an impulsive nature compared to children of a similar age?

Yes No

Find it difficult to wait for instructions to be complete before starting activities?

Yes No

Rush through activities?

Yes No

Appear more fearless during play compared with others of a similar age?

Yes No

Find it hard to stand still for extended periods (e.g. fidgets and wriggles a lot)?

Yes No

7. Muscle readiness for movement

Does your child:

Look floppy compared with their friends of similar age?

Yes No

Have difficulty standing on tip toes?

Yes No

Have difficulty taking steps on tip toes?

Yes No

Have difficulty standing for lengthy periods during play (wants to sit frequently)?

Yes No

Tend to slump forward when asked to sit for an extended period of time on the floor or at the table top?

Yes No

8. Participation

Does your child:

Avoid physical activity/outdoor play (e.g. prefer to play indoors)?

Yes No

Complain that they "can’t do it"/ "don’t want to"?

Yes No

Become frustrated easily in physical play?

Yes No

Appear disinterested in activities that children of similar ages enjoy, despite encouragement?

Yes No

Avoid ball play?

Yes No

9. Persistence in Play

Does your child:

Give up quickly or only participate in small bursts?

Yes No

Get tired quicker than their similar aged friends?

Yes No

Appear to work harder than their friends at the same activities?

Yes No

Become distracted easily?

Yes No

Show limited interest/persistence in learning new activities?

Yes No

10. Playground

Does your child have difficulity:

Climbing over low objects (e.g. adult leg, tyre in the playground).

Yes No

Climbing onto a chair (e.g. climb on forwards, hold onto back of chair, turns around to sit)?

Yes No

Climbing off a chair (e.g. climb down backwards)?

Yes No

Walking along a balance beam with one foot on and one foot off?

Yes No

Following more than one instruction during social play?

Yes No

11. Sports Field

Does your child:

Have difficulty hitting a balloon with a large bat, without losing balance?

Yes No

Have difficulty navigating obstacles (e.g. deciding whether to walk around, over or on when faced with an obstacle course)?

Yes No

Find it hard to walk at a fast pace (beginning to run)?

Yes No

Have difficulty climbing out of a box/laundry basket?

Yes No

Have difficulty kicking a stationary ball towards a target?

Yes No

12. Indoors

Does your child have difficulty:

Mimicking /copying movements of another person?

Yes No

Copying shapes when drawing?

Yes No

Cutting along a line?

Yes No

Eating without getting dirty (around mouth, plate or whole body)?

Yes No

Sustaining interest in indoor play?

Yes No