Gross Motor Development:

1. Seem clumsy and accident prone, frequently fall/trip, or seem to have poor balance?

Yes    No

2. Have difficulty learning new motor movement patterns or motor tasks for age?

Yes    No

3. Tire easily, have a slumped sitting posture, or prop head in hands while at the table?

Yes    No

4. Appear reluctant to participate in sport-type or physical activity, preferring table or floor activities?

Yes    No

5. Look awkward or clumsy while moving- difficulty with crawling, eating, dressing, jumping, or running compared to others his/her age?

Yes    No

6. Have trouble catching and throwing balls of different sizes?

Yes    No

Fine Motor Coordination:

1. Hold utensils awkwardly or with difficulty (crayon or spoon) or drop frequently compared to other same aged children?

Yes    No

2. Have difficulty with or avoid drawing, coloring, copying, or cutting?

Yes    No

3. Switch hands frequently for fine motor tasks- (lack of hand dominance after age 4)?

Yes    No

4. Avoid crossing midline?

Yes    No

5. Have trouble using both hands together for fine motor manipulation compared to peers?

Yes    No

6. Have difficulty controlling grasp- too tight or too loose; unable to let go?

Yes    No

Tactile Development:

1. Seem sensitive to certain textures ,food or fabrics?

Yes    No

2. Avoid or crave messy activities more than other children?

Yes    No

3. Seem unaware of cuts and bruises or over react to it ?

Yes    No

4. Dislike being touched, especially unexpectedly or become irritated when crowded?

Yes    No

5. Crave being touched or having deep pressure hugs more than other children?

Yes    No

6. Seek out rough play with peers, crash frequently into walls, or roll/crash self to floor?

Yes    No

7. Leave clothes twisted on body and puts object in mouth?

Yes    No

Visual Development:

1. Have difficulty discriminating or naming objects or have difficulty recognizing same and different?

Yes    No

2. Make poor eye contact and Have difficulty keeping eyes on still objects?

Yes    No

3. Colors outside the lines, cutting is poor, difficulty copying design

Yes    No

4. Have difficulty with puzzles, using trial and error placement of pieces?

Yes    No

5. Have difficulty locating objects around the room?

Yes    No

6. Tend to look at objects out of the corner of eye or tilt head when looking at something?

Yes    No

Vestibular Development:

1. Get motion sickness easily, seem sensitive to movement, get dizzy, or nauseous easily?

Yes    No

2. Indicate fear of stairs, hills, heights, swinging, or activities requiring balance?

Yes    No

3. Seek lots of movement including: swinging, twirling, bouncing, rocking, and spinning when compared to same aged peers?

Yes    No

4. Have poor endurance for standing and/or sitting posture- seem to require movement to maintain attention?

Yes    No

5. Seem fidgety, always on the go, or have difficulty sitting still?

Yes    No

Auditory Development:

1. Appear overly sensitive to loud noises compared to peers- may be frightened or angry?

Yes    No

2. Hum, sing, chatter, or talk to self during independent play or quiet time more than same aged children?

Yes    No

3. Have a history of repeated ear infections?

Yes    No

4. Have a delay in speech development? expression or receptive speech

Yes    No

5. Have a difficult time discriminating sounds of letters- isolated or in speech?

Yes    No

6. Appear to have difficulty understanding or paying attention to what is said to him/her?

Yes    No

7. Have difficulty following simple directions in comparison to peers?

Yes    No

Oral Motor and Sensory Development:

1. Gag or become distressed at the thought of certain foods?

Yes    No

2. Tend to be a picky eater or react adversely to foods that are typically part of a child’s diet?

Yes    No

3. Tend to crave certain foods?

Yes    No

4. Chew or lick nonfood objects excessively for age (ex: clothing, objects, cheeks or lips)?

Yes    No

5. Overstuff food into mouth compared to same aged children?

Yes    No

6. Drool past the age of 2 years?

Yes    No

Attention and Behavior:

1. Have difficulty organizing or structuring activities?

Yes    No

2. Display poor work behaviors-require more verbal cueing to complete age appropriate tasks than other children?

Yes    No

3. Seem over-reactive or dramatic when compared to same aged peers?

Yes    No

4. Become upset by transitions or unexpected changes?

Yes    No

5. Appear uninterested with group/social activities or tend to withdraw from others?

Yes    No

6. Have difficulty being disciplined?

Yes    No

7. Appear overly affectionate or unaware of personal space?

Yes    No