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 getting up off the floor from lying down without help?

Yes No

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

Yes No

Have difficulty running as fast as their peers of a similar age?

Yes No

Have difficulty slowing down / stopping when running to avoid obstacles?

Yes No

Look awkward when running compared to their friends of similar age?

Yes No

2. Complex Mobility Skills

Does your child have difficulty:

Hopping on the spot, with the same height as their friends?

Yes No

Jumping over a line on the floor?

Yes No

Jumping up in the air, both feet off the floor and together?

Yes No

Jumping down a step with two feet together?

Yes No

Walking up stairs with one foot per step (holding on or not) and down stairs 2 feet per step without holding on?

Yes No

3. Ball skills

Does your child have difficulty:

Catching a soft soccer ball?

Yes No

Kicking a stationary ball without stumbling?

Yes No

Bouncing a ball to another person?

Yes No

Hitting a balloon with a large bat?

Yes No

Throwing a soccer ball to a person 1.5m away with accuracy?

Yes No

4. Standing on one leg (Static Balance)

Does your child have difficulty:

Standing on one leg?

Yes No

Pulling their pants on whilst standing?

Yes No

Stopping a moving ball with one foot without losing balance?

Yes No

Walking sideways, four steps along a balance beam, slowly?

Yes No

Stepping over a raised beam 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

Find it hard to get height in jumping or hopping?

Yes No

Land with a thud when jumping/hopping?

Yes No

Tend to slump at a table top when asked to sit for an extended period of time?

Yes No

8. Participation

Does your child:

Avoid physical activity/outdoor play (e.g. Playground activities)?

Yes No

Complain that the task is "too hard" or 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 skills/sports?

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. Play ground

Does your child have difficulity:

Have difficulty climbing onto and off a chair (eg climb on forwards and turn around and then climb down backwards)?

Yes No

Have difficulty climbing over an ‘A’ frame safely without instructions (e.g. turn at the top of an ‘A’ frame and come down backwards)?

Yes No

Have difficulty navigating an obstacle course correctly and safely?

Yes No

Have difficulty following rules/instructions during social play?

Yes No

11. Sports Field

Does your child:

Have difficulty hitting a balloon, moving ball/shuttle with a large bat?

Yes No

Have difficulty running with the same speed as their similar aged peers?

Yes No

Look as skilful as their similar aged peers when running?

Yes No

Have difficulty kicking a stationary ball into the air?

Yes No

Have difficulty catching a soccer ball in two hands?

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

Threading large beads onto string?

Yes No