Details

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Child's First Name:

Child's Surname:

Age:

 

1. Foundation Mobility Skills

Does your child:

Have difficulty walking on their tip toes with hands on hips for more than 15 feet?

Yes No

Have difficulty walking forwards along a line, slowly, without stepping off?

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 peers of similar age?

Yes No

2. Complex Mobility Skills

Does your child have difficulty:

Hopping more than ten times on the spot, without linking the lifted leg around the other?

Yes No

Have difficulty walking up and down stairs one foot per step without holding on?

Yes No

Hopping with the same height as their same age peers?

Yes No

Hopping forward five meters or more without the other leg touching the floor?

Yes No

Jumping over a 20cm height and landing two feet together?

Yes No

Jumping forward with two feet together 20 times?

Yes No

3. Ball skills

Does your child have difficulty:

Catching a tennis ball in two hands?

Yes No

Running up to and kicking a stationary ball without stumbling?

Yes No

Kicking a ball rolling toward them with accuracy?

Yes No

Hitting a stationary ball with a baseball bat (e.g. ball on a T ball stand)?

Yes No

Throwing a tennis ball to a person 2m away with accuracy?

Yes No

4. Standing on one leg (Static Balance)

Does your child have difficulty:

Standing on one leg for an extended period?

Yes No

Pulling their pants on whilst standing?

Yes No

Stopping a moving ball with one foot without losing balance?

Yes No

Walking 10 steps along a balance beam one foot in front of the other, slowly?

Yes No

Stepping over an object 10 cm tall without losing balance?

Yes No

5. Clumsiness/awkwardness

Does your child:

Have a clumsy manner/lack coordination compared with same aged peers?

Yes No

Trip frequently?

Yes No

Get more hurt when falling down compared with their peers of similar age?

Yes No

Have difficulty maintaining balance while moving through an obstacle course?

Yes No

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

Start before instructions are completed?

Yes No

Rush through activities?

Yes No

Approach more complex activities fearlessly 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 ages?

Yes No

Have flat feet?

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?

Yes No

Complain that the task is "too hard" or they "can’t do it"?

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 in play?

Yes No

Show limited interest/persistence in learning new skills?

Yes No

10. Playground

Does your child have difficulity:

Like to play in the playground?

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

Have difficulty skipping along in the same manner as their friends?

Yes No

11. Sports Field

Does your child:

Have difficulty hitting a ball/shuttle with a bat?

Yes No

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

Yes No

Look as skilful as their similar aged friends when running?

Yes No

Have difficulty kicking a moving or stationary ball with accuracy?

Yes No

Have difficulty catching a tennis ball in two hands?

Yes No

12. Indoors

Does your child have difficulty:

Copying shapes when drawing?

Yes No

Cutting along a line?

Yes No

Cutting along a line?

Yes No

Threading beads onto a string with ease and speed?

Yes No

Staying within the lines when colouring in?

Yes No