Name: ______________________________ Nickname: ________________ 5.

Follows 2-step instructions that include

Date of Birth:_________________________ Age: ________ simple preposition.
Sex: _______ TOTAL SCORE
EXPRESSIVE LANGUAGE DOMAIN
4. Feeds self using fingers with spillage.
GROSS MOTOR DOMAIN EXPRESSIVE LANGUAGE PRESENT COMMENTS
5. Fedds self using fingers without spillage.
GROSS MOTOR PRESENT COMMENTS 1. Uses 5-20 recognizable words.
6. Eats without need for spoonfeeding during
1. Climbs on chair or other elevated piece of 2. Uses pronouns (e.g. I, me, ako, akin)
any meal.
furniture like a bed without help. 3. Uses 2-3 words verb-noun combinations (e.g.
7. Helps hold cup for drinking.
2. Walks backwards hingi gatas).
8. Drinks from with spillage.
3. Runs without tripping or falling. 4. Names objects in pictures.
9. Drinks from cup unassisted.
5. Speaks in grammatically correct 2-3 word
4. Walks down stairs, 2 feet on each step, with 10. Gets drink for self unassisted.
sentences.
one held. 11. Pours from pitcher without spillage.
6. Asks “what” questions.
5. Walks upstairs holding handrail, 2 feet on 12. Prepares own food/snack.
7. Aks “who” questions.
each step. 13. Prepares meals for younger siblings/family
8. Gives account of recent experiences (with
6. Walks upstairs with alternate feet without members when no adults is around.
prompting) in order of occurence using past
holding handrail. 14. Participates when being dressed(e.g., raises
tense.
7. Walks downstairs with alternate feet without arms or lifts leg).
TOTAL SCORE
holding handrail. 15. Pulls down gartered short pants.
COGNITIVE DOMAIN
8. Moves body parts as directed. 16. Redmoves sando.
COGNITIVE PRESENT COMMENTS
9. Jumps up. 17. Dresses without assistance including
1. Looks at direction of fallen object.
buttons and tying.
10. Throws ball overhead with direction. 2. Looks dor partially hidden object.
18. Dresses without assistance except for
11. Hops 1-3 steps on preffered foot. 3. Immitates behavior just seen a few minutes
buttons and tying.
earlier.
12. Jump and turn. 19. Informs the adult only after he has already
4. Offers object but will not release it.
13 Dances patterns/joins group movement urinated (peed) or moved his bowels
5. Looks for completely hidden object.
activities. (poohed) in his underpants.
20. Informs adult of need to urinate (pee) or 6. Exhibits simple pretend play (feed, put doll to
TOTAL SCORE slep).
moved bowels (pooh-pooh) so he can be
FINE MOTOR DOMAIN brought to designated place (e.g. comfort 7. Matches objects.
FINE MOTOR PRESENT COMMENTS room). 8. Matches 2-3 colors.
1. Uses 5 fingers to get food/toys placed on flat 21. Goes to the designated place to urinate 9. Matches pictures.
surface. (pee) or move bowels (pooh) and never 10 Sorts based on shapes.
2. Picks up objects with thumb and index does this is his underpants anymore> .
finger. 22. Goes to the designated place to urinate 11 Sorts objects based on 2 attributes (e.g. size
3. Display a definite hand preference. (pee) or move bowels (pooh) and never . and color).
4. Puts small objects in/out of containers. does does this is his underpants anymore. 12 Arranges objects according to size from
5. Holds crayon with all the fingers of his hand 23. Wipes/clean self after a bowel movement.. . smallest to biggest>
making a fist(i.e, palmar grasp) 24. Participates when bathing (e.g. Rubbing 13 Names 4-6 colors.
6. Unscrews lid of container or unwraps food. with soap). .
7. Scribbles spontaneously. 25. Washes and dries hands without any help. 14 Copies shapes.
8. Scribbles vertical and horizontal. 26. Washes face without any help. .
9. Draws circle purposely. 27. Bathes withou any help. 15 Names 3 animals or vegetables when asked.
10. Draws a human figure( head, eyes, trunk TOTAL SCORE .
arms, hand /fingers). RECEPTIVE LANGUAGE 16 States what common household item are
11. Draws a house using geometric forms. RECEPTIVE LANGUAGE PRESENT COMMENTS . used for.
TOTAL SCORE 17 Can assemble simple puzzles.
1. Points to family members when asked to
SELP-HELP DOMAIN do so. .
SELP-HELP PRESENT COMMENTS 18 Demonstrates an understanding of opposites
2. Points to 5 body parts on himself when
1. Feeds self with finger food(e.g, biscuits, asked to do so. . by completing a statement (e.g. Ang aso ay
bread) using fingers. malaki. Ang daga ay maliit.)
3. Points 5 named picturd objects when asked
2. Feeds self using spoon with spillage to do so. 19 Points to left and right side of the body.
3. Feeds self using spoon without spillage. .
4. Follws one-step instructions that include
simple prepositions (e.g. in, on, under, etc.) 20 Can state what is silly on wrong with pictures
.
21
(e.g. Ano ang mali sa larawang ito?)
Matches upper and lower case letters.
Philippine Early Childhood
. Development Checklist
TOTAL SCORE
SOCIAL EMOTIONAL DOMAIN
Form 2
SOCIAL-EMOTIONAL PRESENT COOMENTS (3.0-5.11 years old)
1. Enjoys watching activities of nearby people or
animals.
2. Friendly with strangers but initially may show
slight anxiety or shyness.
3. Plays alone but likes to be near familliar adults
or brothers and sisters.
4. Laughs or squels aloud in play.
5. Plays peek-a-boo (bulaga).
6. Rolls ball interactively with
caregiver/examiner.
7. Hugs or cuddles toys.
8. Demonstrates respect for elders using terms
like “po” and “opo”.
9. Shares toys with others.
10 Immitates adult activities (e.g. cooking,
. washing) JUNE OCTOBER MARCH Child’s Name:
11 Identifies feelings in others. Birthdate: Age: S.Y:20-2021
.
12 Appropriately uses cultural gestures of
Sum of LRN: Sex: Male
. greeting without much prompting (e.g. mano, Scaled Scores
bless, kiss, etc.)
13 Comforts playmates/siblings in distress.
.
Standard
Score ZENAIDA G. GULAY. ILLYN C.TAPAYA
14 Persists when faced with problem or obstacle
. to his wants. PARENT’S/GUARDIAN NAME AND SIGNATURE ES PRINCIPAL I TEACHER
15 Helps with family chores( e.g. wiping tables, Interpretation
. watering plants, etc.)
16 Curious about environment but knows when
of Standard
JUNE
. to stop asking questions of adults. Score
OCTOBER
17 Waits for turn. MARCH
.
18 Asks permission to play with toy being used by
. another.
19 Defends possessions with determination.
.
20 Plays organized group games fairly (e.g. does
. not cheat in order to win).
21 Can talk about difficult feelings (e.g. anger,
. sadness, worry) he experiences.
Republic of the Philippines
22 Honors a simple bargain with caregiver (e.g.
. can play outside only after cleaning/fixing his Department of Education
room). Region IV – MIMAROPA
23 Watches responsibly over younger LUBANG INTEGRATED SCHOOL
. siblings/family members. Lubang
24 Cooperates with adults and peers in group
. situations to minimize quarrels and conflicts.
TOTAL SCORE