T.O.

EVALUATIONS

NUMBER. INDEX. PAGE.

1.  Game Scale. 2-9.

2.  Playfulness. 10-11.
3.  Developmental Evaluation. 12-19.
4.  Activities of Daily Living (ADL). 20-23.
5.  List of Roles. 24-27
6.  Occupational Self-Assessment. 28.
7.  Environmental Assessment. 29.
8.  Level of Interest in Activities. 30-33.
9.  The level of Interest in Particular Activities. 34-35.
10.  Volitional Questionnaire Form. (Multiple Observation). 36.
11.  Volitional Questionnaire Form. (Single Observation). 37-38.
12.  Activity Analysis Protocol. 39-42.
13.  Evaluation of Play Behavior. 43-45.
14.  Evaluation of the General Interest of the Child. 46.
15.  Assessment of Interests and Basic Play Skills. 47.
16.  Assessment of Interests and Basic Play Skills. 48-49.
17.  Characteristics of the Playful Attitude of the Child in General. 50-51
18.  Synthesis of Results. 52.
19.  Initial Interview with Parents about their child's Play Behavior. 53.
20.  What is your child particularly interested in/attentive to? 54-58.
21.  Evaluations of daily occupations. (Cake of life). 59-60.
22.  L.O.T.C.A. Score Sheet. 61-62.
23.  Functional Capacity Evaluation. 63.
24.  Assessment of Functional Skills / A.V.D. 64-65.
25.  Evaluation of Activities of Daily Living. 66-67.
27.  Sensory Integration Observation Guide for 0 - 12 months. 68-71.
28.  Sensory Rating Scale for Infants and Young Children. 72-76.
29.  Scoring Form. 77-78.
30.  Observation of Hand Skills. 79-80.
31.  History of Sensory Integration Development. 81-89.

Occupational questionnaire.
AMPS
Communication/interaction skills assessment
dunning environmental questionnaire
 dsll assessment
muscle scan
muscle assessment protocol
muscle strength assessment form
AVBD barthel scale
katz index (AVBD)
copm
comprehensive assessment scale of to
Susan Knox Play Scale.

Description of dimensions:

1- Space management: the way the child manages his or her body and space. This includes the
following factors.
- Gross motor activity: play involves the whole body.
- Interests: attention to specific types of activities.

1- Material handling: the way the child handles the material around him/her. This consists of the
following factors.
- Manipulation: fine motor games.
- Construction: combining objects and making products.
- Purposes: goals of the activity.
- Attention: duration in independent playing time.

1- Symbolic (make believe): the way the child learns about the world through imitation and the
development of skills to understand and separate reality from fantasy. It includes the following
factors:
- Imitation: imitating aspects of the cultural environment.
- Dramatization: make-believe, introduction of the new and imitation of roles.
1- Participation: the amount and mode of social interaction. It includes the following factors.
- Type; level of social interaction in the game.
- Cooperation: ability to cope with others in the game.
- Humor: understanding and expressing expressions of humor according to events.
- Language: communicating with others in the game.

SCALE OF THE GAME.

Name: Evaluator: Location:

Gender: Date: Time:

1. Ages of the game dimensions:

Space management: ___________________________ Imitation: ________________
Materials handling: __________________________ Participación: ______________
Age of the game (average of the four dimensions) __________________________
Chronological age _________________________
Diagnóstico _____________________________

2. Additional behavioral comments: (include areas such as general description of behaviors, lack of
any of the dimensions, and any unusual behaviors).

SCALE OF THE GAME.

Susan Knox.

0 - 1 YEARS 1 - 2 YEARS
Space GROSS MOTOR ACTIVITY GROSS MOTOR ACTIVITY.
management
Reach, sleight of hand and Stand, sit, walk, sit, walk
feet, movements directed to to low objects.
sensa
Pleasant sessions.
TERRITORY.
TERRITORY In the house and immediate
surroundings.
Cradle, corral, house.
EXPLORATION.
EXPLORATION. Of all non-family objects
From self and objects to the Res, from the obvious to the
scope. Casual.

COMMENTS. COMMENTS.

Material HANDLING. HANDLING.

handling
Take mouth toys, bring 2 Throw, lift, insert, pull, aca.
objects together, collect. Rrea, fist blows, grip.

CONSTRUCTION. CONSTRUCTION.
It is not yet evident. Combine 2 objects, make
towers,
take apart, put together.
INTEREST.
People. INTEREST.
Movement and moves objects.
PURPOSE.
Sensations or function. PURPOSE.
Experiment with movements
and
COMMENTS. Processes.

COMMENTS.

Imitation. IMITATION. IMITATION.

Of expressions, emotions, abra Of present events, adults,
children, children's
za toys. Nes mimicry, domestic mimicry
(te
phone, sweeping).
IMAGINATION AND
DRAMATIZATION
Not evident. IMAGINATION AND
 DRAMATIZATION
Not yet evident.
MUSIC.
Pay attention to the sounds. MUSIC.
Listen, it rocks.
COMMENTS.
COMMENTS.
BOOKS.
Near the end of the first year, it BOOKS.
hits
Affectionately. Take, write down the drawings.

COMMENTS. COMMENTS.

Participation. TYPE. TYPE.

Solitary up to 30 min. enjoy Solitary, spectator, hidden
being
Company, to be rocked. And found.

COOPERATION. COOPERATION.
Needs personal attention (7 - Offers toys, but possessively
10)
He prefers to start games rather persistent, helps to save the
than
Guilos. Toys.

LANGUAGE. LANGUAGE.
Enjoy the noise, pay attention. Enjoy the noise during the
game.

COMMENTS. COMMENTS.

2 - 3 YEARS. 3 - 4 YEARS.
Space GROSS MOTOR ACTIVITY. GROSS MOTOR ACTIVITY.
management
It includes the whole body, Jump, run, climb, love to the
jumps, throws.
vehicles.
TERRITORY.
Outside, short excursions. TERRITORY.
Home, immediate
neighborhood.
EXPLORATION.
Age of discovery. EXPLORATION.
Interest in new experiences,
place
 COMMENTS. Beef, animals, nature.

COMMENTS.

Material HANDLING. HANDLING.

handling.
Feel, tap, tap, tap, tap, tap, tap, Small muscular activities,
tap, tap, tap, tap, tap, tap, tap,
tap, tap, tap, tap, tap.
Squeeze, push, pull. Hammering, separates, inserts
small objects, inserts
small, short.
CONSTRUCTION.
Build with blocks, puzzles CONSTRUCTION.
(4 - 5 pieces) Combine game stuff, take apar
tion, simple products and evi
INTEREST. Dentes.
Small things, moving parts,
Messy. INTEREST.
Anything good.
PURPOSE.
Prefer the process rather than PURPOSE.
the re
Results. Prefer the process rather than
the re
results.
ATTENTION.
Intense interest, silent play ATTENTION.
Up to 15 min. Longer period (30 min.
Approximates
damente.
COMMENTS.
COMMENTS.

Imitation. IMITATION. IMITATION.

Domestica (house, dolls as Continued but more complete.
Bebe) and animals.
IMAGINATION.
IMAGINATION. Very important, it assumes
roles, "does
It starts with imaginary friends. How."

DRAMATIZATION. DRAMATIZATION.
Not evident. Mirrors experiences.

MUSIC. MUSIC.
 Movements, actions. Sing simple, instrumental
songs
cough.
BOOKS.
Look, touch, like stories fa BOOKS.
Milestones, add words and He likes new books, books of
phrases.
information, important images.
COMMENTS.
COMMENTS.

Participation. TYPE. TYPE.

Parallel, play with partners has Associative, group of 2 to 3
substitutes
1 or 2 hours. Enjoy your companions.

COOPERATION. COOPERATION.
Small sociability of giving and Limited, asks for things, keeps
receiving the ju
seize and hold, independence, with supervision. Emo Sample
initiates
their own games, they do not cation towards toys.
ask for help,
Helps to store toys, likes to
a place of its own. LANGUAGE.
He is interested in words and
their meaning.
LANGUAGE. Nified.
Conversationalist.
COMMENTS.
COMMENTS.

4 - 5 YEARS. 5 - 6 YEARS.
Space GROSS MOTOR ACTIVITY. GROSS MOTOR ACTIVITY.
management
It includes the whole body, it is Good muscle control and
incarnated, balance,
Jump and throw. Prancing, ram turns, ladder,
patina, iza.
TERRITORY.
Neighborhood. TERRITORY.
Above ground.
EXPLORATION.
Anticipated travel, likes to EXPLORATION.
change
Gait. Plan and enjoy excursions
 and travel.
COMMENTS.
COMMENTS.
Material HANDLING. HANDLING.
handling.
Pull, strength and speed Combination of materials, uses
evident. he
Tools to get things done.
INTEREST.
Pride in work, ideas complica INTEREST.
Das. Miniatures, making things
usable,
Product permanence.
PURPOSE.
Exaggeration. PURPOSE.
Reality.
ATTENTION.
Entertains up to 1 hour. ATTENTION.
Concentration for long periods
of
COMMENTS. Time.

COMMENTS.
Imitation. IMITATION. IMITATION.
Adult, housework, dressing The same, important
costumes.
I know, important reality.
IMAGINATION.
IMAGINATION. Continued.
Prominent, oriented.
DRAMATIZATION.
DRAMATIZATION. Act out stories, familiar things,
"Disappear." Here and now.

MUSIC. MUSIC.
Sing, dance, good rhythm. He knows melodies and songs.

BOOKS. BOOKS.
Listen better, you don't need They must be credible,
more with repetition of the
Physical touch with books. Family.

COMMENTS. COMMENTS.

Participation. TYPE. TYPE.

Cooperative, group of 2 to 3 Cooperative, group of 2 to 5
 partners friends
favorite games, some solitaire Des, becoming stronger and
games. stronger
pos of games.
COOPERATION.
Take turns, put away toys COOPERATION.
without
Supervision. Limited to the partnership of
giving and receiving
bir, rivalry.
LANGUAGE.
Very talkative, manufactures, LANGUAGE.
boasts,
Threats, clowning around. Interested in the here and now,
how, why, what for.
COMMENTS.
COMMENTS.

Evaluation of Playfulness.

Name: __________Extension Intensity. Skills.

3. Almost always. 3. High. 3. High.
Age: ____________ 2. Most of the time. 2. Moderate. 2. Moderate.
1. Sometimes. 1. Mild. 1. Mild.
Date: ___________ 0. Rarely or never. 0. No. 0. No skills.
N.A. Not applicable. N.A. Not applicable. N.A. Not applicable

Item Extensio Intensity Skills Comments

n.

He is actively engaged.
Shown self-directed. Decide what to do and how
do so.
Shows a sense of security.
Demonstrates evident and manifest exuberance
enjoy it.
Try to overcome difficulties, barriers or
 obstacles to persist in the activity.
Actively modifies the demand or
complexity of the activity.
Participates in pranks or commits a
minor infringement of implicit or explicit rules
Repeats actions, activities and remains on the
subject of
base.
It is committed to the different aspects
of the activity process .
The how yes. (Pretends).
Incorporates within the game objects or other
people from
imaginative, unconventional or changes direction
Participates in challenges (motor, cognitive or
social).
Negotiates with others for their needs or
to satisfy their desires.
Play with others.
Play interactively with others.
Assumes the role of leader.
Join a group that is already doing an activity.
Initiate the game with others.
Teases or teases others (verbal or nonverbal).
Acting funny.
Share toys and play equipment.
Gives verbal, facial and body cues
appropriate to the situation and says, "This is just
like
I would like you to behave with me.
Responds to another's facial and body cues
Consistently maintains the framing of the game.
From: Bundy, A. (1997) Play and playfulness: What to look for, in Partham, D. & Fazio, L., Play
in Occupational Therapy for Children. pp. 52-66
 DEVELOPMENTAL ASSESSMENT.

Patient's name:
Date of birth:
Check the items observed in the column.

Age Level Items.

Evaluation date.

1 MONTH.
Engine.
1. Hands close on contact __________________________________________
2. Lie down with your head turned to one side _______________________
3. Rola part of the path from supine to lateral __________________________________
4. The head is left behind when traction is applied to seat it _________________
5. In prone position slightly raise the head ____________________________
Reflexes.
1. Primary reactions, medullary and lower brainstem reflexes are present
_______________________________________________________________
Manual use.
1. Immediately drops the rattle if touched in the hand __________________

3- 4 MONTHS.
Engine.
1. Prone position on forearms, fully raise the head _____________
2. Lateral head control ________________________________________________
3. Rola from supine to lateral _________________________________________________
4. Slight backward displacement of the head when pulled for sitting
_______________________________________________________________
5. Supported seated, firm head, lumbar curvature __________________________
6. Held stationary, briefly supports a small part of the weight _____________
7. Symmetrical posture of head and arms ______________________________________
Reflexes.
1. Absent prehension reflex (voluntary prehension in development) ____________
2. Neck straightening reflex present _______________________________
3. Decreased asymmetric cervical tonic reflex and asymmetric cervical tonic reflex.
tónico laberíntico __________________________________________________________
4. Prone labyrinth straightening present ______________________________
Manual use.
1. Arms mobilize at the sight of a toy __________________________________
2. Actively holds a toy (drops it) _______________________________
3. Look at the cube from the hand, you can touch it ____________________________________
4. Holds a hoop and puts it in his mouth ______________________________________

1. - 7 MONTHS.
Engine.
1. In the supine position, raise the head up ______________________________________.
2. Rola to supine decubitus __________________________________________________
3. Rola to prone position __________________________________________________
4. Lifts head and assists when pulled to sit ________________
5. Sits alone momentarily, resting his hands on his back, supports much of the weight and
bounces _______________________________________________________.
6. Reciprocal leg pattern _____________________________________________
7. Bring your feet to your mouth __________________________________________________
Reflexes.
1. Appearance and continuation of the defense extension thrust ___________________________
2. Supine labyrinthine straightening reflex and body straightening reflexes present
_______________________________________________________
3. Symmetrical cervical tonic reflex, asymmetrical cervical tonic reflex and labyrinth tonic reflex
absent ____________________________________________________
Manual use.
1. Transfers objects and puts them in the mouth ___________________________________
2. Touch your image in the mirror ______________________________________________
3. Holds an object in each hand __________________________________________
4. Hits objects (shakes the rattle) ________________________________________
5. Reach with one hand __________________________________________________
6. Keeps feet in mouth ______________________________________________
Personal care.
1. Chew solid foods well _____________________________________________
2. Starts to drink from a cup, prefers bottle ________________________
3. Anticipates spoon feeding, sucks food from spoon _____

9 - 10 MONTHS.
Engine.
1. Take a crawling position on hands and knees ______________________________
2. Crawls on all fours (reciprocally) ___________________________________
3. Adopt a sitting position ______________________________________________
4. Sits indefinitely with good control _________________________________
5. Pulls on furniture to sit _______________________________________
6. From a standing position, it is lowered to the floor
___________________________________________
7. From seated position to prone _______________________________________
Reflexes.
1. Equilibrium reactions in quadruped position (8 months) ____________________
2. Beginning of equilibrium reactions in seated position (10 months) _____________
Manual use.
1. Scan with the index finger lower clamp between thumb and forefinger _________________
2. Play with two objects at the same time _____________________________________
3. Bring two objects together __________________________________________________
4. Shake and shake a bell _____________________________________________
5. Loose in rough form ___________________________________________________

Personal care.
1. Holds his bottle ___________________________________________________
2. Pretend to drink from a cup ______________________________________________
3. Eats bits of spilled food with fingers _________________________

1 YEAR.
Engine.
1. Makes pivot sitting _____________________________________________________
2. He kneels down and keeps his balance in that position __________________________
3. Steps to the side of a railing __________________________________
4. Walk, holding a hand __________________________________________
5. Sits from prone position ____________________________________________
6. Crawls freely on hands and knees ___________________________________
Manual use.
1. Try to make towers of two cubes _________________________________________
2. Give the toy on request ________________________________________________
3. Prehension in upper clamp _____________________________________________
4. Offer the ball without releasing it ______________________________________________
5. Place a bead in a cup ____________________________________________.
6. Enjoy games such as "peek - a - boo" ______________________________
Personal care.
1. Eat food from a tray with your fingers _______________________________
2. Collaborate with _________________________________________________
3. You can drink small amounts from a cup _______________________________
4. You can hold a spoon and drag it through the tray _______________.
5. He is interested in taking off his hat, shoes, pants ___________________________

1 YEAR AND 3 MONTHS.

Engine.
1. Walks alone for several steps (stands only 14 months) ____________________________
2. Falling down sitting _________________________________________________________
3. Crawl up stairs _________________________________________________
4. He gets up on his own and walks _________________________________________________
5. Can crawl up stairs _________________________________________
Manual use.
1. Makes towers of two cubes ________________________________________________
2. Place pellets in a bottle and like to turn them upside down _____________________________
3. Throws the ball awkwardly, throwing is his favorite pastime ________________
4. Place six cubes in a cup and take them out ____________________________________.
5. Displays or offers toys _______________________________________________
6. It gets into everything ________________________________________________________
7. Helps to turn the pages of a book, clap them ____________________________
Pre-writing.
1. Imitative strokes with a wax crayon ____________________________________
Personal care.
1. Discard the bottle __________________________________________________
2. He takes off his shoes _____________________________________________________
3. He still prefers to eat with his hand __________________________________________
4. Rudiments for toilet use, you can sit on it ___________________
5. It can hold the spoon and cup in a simple way __________________________
6. You can drop the plate on the tray ______________________________________

1 YEAR AND A HALF.

Engine.
1. Walks alone, rarely falls, runs stiffly ___________________________
2. Climb steps holding hands ______________________________________
3. Sits alone in small chair ____________________________________________
4. Climbs on an adult chair ____________________________________________
5. Walk with a big ball ___________________________________________
6. Pulls a wheeled toy while walking backwards ___________________
Manual use.
1. Place 10 cubes in a cup ______________________________________________.
2. Empty a container _____________________________________________________
3. Turn the pages of a book 2 or 3 at a time ________________________________
4. Throw the ball _________________________________________________________
5. Build a tower of 3 or 4 cubes ________________________________________
6. Throw a toy ________________________________________________________
Pre-writing.
1. Garabateos espontáneos _________________________________________________
2. Imitative stroke with wax crayon __________________________________________
Personal care.
1. Cap, shoes and socks removed __________________________________________
2. Download a large zipper ___________________________________________________
3. Eat only in part, spill _____________________________________________
4. Shoes are placed _______________________________________________________
5. Regular bowel and bladder control habits during the day ______________________

1 YEAR AND 9 MONTHS.

Engine.
1. Climb stairs supported by a handrail _________________________________
2. Go down stairs holding one hand _____________________________________
 3. Squats to play ___________________________________________
Manual use.
1. Build a tower of 5 or 6 cubes ____________________________________________
2. Places blocks on a lace board _________________________________________

2 YEARS.
Engine.
1. Runs quite well _____________________________________________________
2. Walk up and down stairs alone, without alternating feet ____________________________
3. Kick the ball _________________________________________________________
Manual use.
1. Rotates forearm, can turn knobs _______________________________________
2. Turn pages by one ___________________________________________________
3. Three cube towers ____________________________________________________
4. Places blocks on the snapping board after demonstration _________________
5. Place 2 or 3 cubes in a row for a train _______________________________.
6. Fits on the reverse side of the socket board (4 tests) __________________________
7. Thread 3 beads (2,5 cm.) ______________________________________________
Pre-writing.
1. Imitates awkwardly vertical stroke ___________________________________________
Personal care
1. Holds glass or cup with one hand ________________________________________
2. Avoid overbending the spoon ___________________________________________
3. May eat alone, may not want to _________________________________
4. He takes off shoes, socks, pants _______________________________________
5. Place both legs on one pant leg ___________________________.
6. Verbalizes need to use toilet during the day, regularly _____________

2 YEARS AND 6 MONTHS.

Manual use.
1. Grip with too much force, release with hyperextension _______________________
2. Tower of 8 cubes _______________________________________________________
3. Matching of a shape and color ____________________________________
4. Places blocks on snapping board, no demonstration _________________________
Pre-writing.
1. Imitates horizontal stroke ___________________________________________________
2. Holds crayon with fingers ________________________________________

2. YEARS.
Engine.
1. Walk on tiptoe _________________________________________________
2. Run on your toes _____________________________________________
3. Ride a tricycle ________________________________________________________
4. Jump on both feet __________________________________________________
5. Climb stairs alternating feet _________________________________________
6. Stands on one foot momentarily ___________________________________
Manual use.
1. Fits on the reverse side of the lace board, no errors _______________________
2. Tower of 9 to 10 cubes ___________________________________________________
3. Imita puente ___________________________________________________________
4. Good wrist deflection _____________________________________________
5. Pairing of three shapes and three colors ______________________________
Pre-writing.
1. Imita cruz _____________________________________________________________
2. Copia circulo __________________________________________________________
Personal care.
1. Undoes accessible buttons ____________________________________________
2. Eat alone, spill little ________________________________________________
3. He undresses, except for the clothes on his back _______________________________
4. Pants, socks, shoes ______________________________________
5. Cannot distinguish back from front ___________________________________
6. Pour liquids well from a pitcher __________________________________________

3. YEARS AND 6 MONTHS.

Engine.
1. Stands on one foot for 2 seconds _______________________________________
2. Motor incoordination, stumbles, falls, fear of heights ______________________
3. Often the tensional expressions are exaggerated _______________________
Manual use.
1. Builds bridge following the model, without demonstration ______________________
2. Manual tremor may be evident ____________________________________
Personal care.
1. Stands up and dries hands and face ____________________________________________

4. YEARS.
Engine.
1. Stand on one foot, 4 - 5 seconds _______________________________________
2. Walk down stairs with alternating feet _________________________________________
3. Jump on one foot ______________________________________________________
Manual use.
1. Overhead pitch ___________________________________________
2. Cut with scissors on a line __________________________________________
3. Handsaw with handsaw __________________________________________
4. Holds the brush in an adult fashion _______________________________________
5. Can count, correctly pointing out 3 objects ____________________________
Pre-writing.
1. Copy a cross with crayon __________________________________________
2. Roughly draws some relatives ______________________________________
Personal care.
1. Combines talking and eating, talking and dressing _________________________________
2. Dresses with some assistance, the garments must be fitted ________________
3. Dresses self, except for tying bows and fastening back buttons ___.
4. Need minimum directives for bathing (which part to wash) ______________
5. You can help to plan and prepare your own food ______________________
6. Brush your teeth ____________________________________________________
7. Some can fasten buttons ________________________________________
8. Distinguish the front from the back _______________________________________

5. YEARS.
Engine.
1. Jump alternating feet _________________________________________________
2. Balance on one foot (8 seconds) _______________________________________
3. Walk on a plank the entire length of ______________________________________.
4. Runs, climbs on chairs, tables ____________________________________________
5. Likes to march (to the beat of the music) _________________________________
6. Jump from the height of a table _________________________________________

Manual use.
1. He uses his hands more than his arms to catch a small ball but often drops it
_________________________________________________
2. You can tell how many fingers you have on one hand _______________________________
3. Accurately grab and quickly release ___________________________________
4. He likes to copy simple shapes ___________________________________________
5. Paint on the floor, with paintbrushes and large sheets of paper _____________________
6. You can sew using cardboard ___________________________________________
7. Place fingers on piano keys, experiment with chords _________
8. Manipulates the sand by building roads and houses ___________________________
9. Mold objects with plasticine _____________________________________________
10. Construction with blocks, roads, winding structures, small fences __
Pre-writing.
1. Likes to color within limits, can cut and paste ________________
2. Copy a square _____________________________________________________
3. Draw a picture, recognize that it's funny ________________________________
Personal care.
1. Button fasteners that you can see ___________________________________________
2. Pass the shoelaces __________________________________________
3. He dresses himself completely ______________________________________________
4. Neglect your clothing, you may lack motivation ______________________________
5. Distinguish right from left in yourself, not in your shoes _________________

6. YEARS.
Engine.
1. Very active, almost constantly on the move _____________________________
2. Sometimes clumsy __________________________________________________________
3. Active body balance in games: jumping and hammock ________________________
4. Jumps from a height of 30 cm. Falling on toes ________________
5. Stands on alternating feet, eyes closed _____________________________
6. Throws objects in the distance __________________________________________________
Manual use.
1. Handles and attempts to use tools and materials _________________________
2. Need help completing projects ________________________________
3. More thoughtful, sometimes unreflective __________________________________________
4. Cut and paste, making paper boxes and booklets ____________________________
5. Hammer hard, hold hammer close to head ____________________
6. Better control of your own speed, but fearful of speed in a car or large skateboard
________________________________________________________
7. Interested in his own and strength and in lifting objects ________________________
8. He often adopts strange postures _____________________________________
Manual use.
1. Holds hammer and hammers well ________________________________________
2. Saw with ease and precision _________________________________________
3. Make a finished project ___________________________________________
4. Proper use and handling of garden tools _____________________
5. Build complex structures with construction kits _________________
6. Drawing, begin to outline, drawings with details, likes to draw still lifes, maps and designs
________________________________________________
7. Girls can cut and sew simple garments, they can knit ________________.

Compiled by Nancy C. Marke, O.T.R and Anna Deana Scott, O.T.R of the Children's
Rehabilitation Center", University of Virginia Hospital, Charlottesville, Virginia, U.S.A.
 ACTIVITIES OF DAILY LIVING.

SR: DATE OF INITIAL TEST ___________ PATIENTS EXT. / INT.

MRS:
NAME: STA. ______________EDAD _____HAB. _______MEDICO ___________
DIRECCION ____________________________OCUPACION: ___________________
DIAGOSTIC:________________________________ ADMISSION DATE _____
CAUSAS: ________________________________________________________________

METHOD OF RECORDING THE TEST AND SYMBOLS FOR

QUALIFY THE PROCESS

I - the patient can perform the activity independently.

S - patient needs supervision.
A - patient needs assistance.
L - patient needs to be lifted.
X - the activity is not indicated.

In the initial evaluation: use BLUE PEN.

Enter the rating symbol in the

column G / 1 and your initials in column 1.

The start date appears at the top of

the page.
Progress: recorded with RED PEN.

Enter the rating symbol in the

column G / 2 and their initials in column 1.

The date in the "Date" column.

ACTIVITIES IN BED G / 1 G / 2 DATE 1

Mobility in bed: lying down, sitting.

Rolled to the right: to the left.
Rotate on the abdomen.
Handling: pillow, blanket.
Seated.
Reach for objects on the light table.
Operate light switch.

WHEELCHAIR ACTIVITY.

Propulsion: forward, backward turning.

Open, pass and close the door.
Up and down the ramp.
Wheelchair bed.
Wheelchair to bed.
Wheelchair to regular chair.
Common chair to wheelchair.
Wheelchair to sofa.
Sofa to wheelchair.
Wheelchair to toilet (adapted or common).
Wheelchair toilet.
Adjust clothing.
Wheelchair to bathtub.
Bathtub to wheelchair.
Wheelchair to shower (chair in shower or bathtub).

TRAVEL.
Wheelchair to car - on cord.
Auto to wheelchair - on curb.
Wheelchair to car - without cord.
Auto to wheelchair - without cord.

TRAVEL.
Putting wheelchair in car - on sidewalk, street.

SELF-CARE ACTIVITIES
HYGIENE (Toileting activities).
Combing, brushing hair.
Brushing teeth.
Shaving (electric shaver, gillete), putting on make-up.
Open the faucet.
Wash, dry hands and face.
Washing, drying the body and extremities.
Taking a bath (wheelchair, standing).
Taking a shower (wheelchair, standing).
Use urinal.

FOOD ACTIVITIES.
Eating with a spoon.
Eating with a fork.
Cutting food.
Handling: straw, cup, glass.

CLOTHING ACTIVITIES.
T-shirt, bra.
Shorts, panties.
Putting on clothes.
Shirt, blouse.
Pants, dress.
Socks, stockings.
Shoes (laces, buckles, shimming).
Coat, jacket.
Braces, prosthesis, corsets.

VARIED HAND-HELD ACTIVITIES.

Enter your name and address.
Operation: watch.
Matches or lighter.
Cigarette.
 Book, newspaper.
Handkerchief.
Lights: switches, knobs.
Telephone: receiver, dial, coins.
Handling: coin purse, coins, paper money.

WALKING ACTIVITIES.
Open, pass and close the door.
Walking outdoors.
Walking transporting.

STAND UP AND SIT DOWN.

Getting up from a wheelchair.
Sitting in the wheelchair.
Getting out of bed.
Sitting up in bed.
Getting up from the common chair.
Sitting in the common chair.
Rise from the common chair at the table.
Sitting in the common chair at the table.
Getting up from the sofa.
Sitting on the sofa.
Rising from the center of the couch.
Sit in the center of the sofa.
Getting up from the toilet.
Sitting on the toilet.
Adjust clothing.
In the car.
Outside the car.
Sitting on the floor.
Getting up from the floor.

STEP CLIMBING ACTIVITIES AND

DISPLACEMENT.
Climbing stairs (with handrails, without handrails).
Descending stair steps (with handrails, without
handrails).
Getting in or out of a cab.
Walk one block and back.
In the collective:
To sit down, to get up from the seat.
 Getting off the bus.

COMMENTS:

TAKEN FROM THE CHAPTER, ACTIVITIES OF DAILY LIVING, MURIEL E.

ZIMMERMAN, MS.O.T.R., OF THE INSTITUTE OF REHAB.MEDICINE, NEW YORK
UNIVERSITY.

LIST OF ROLES.

NAME: _____________________________AGE: ____________DATE: _______

GENDER: ___________________ARE YOU RETIRED: _______________________
MARITAL STATUS: ________SINGLE: ______MARRIED: ______ SEPARATED: ____
DIVORCED: ________________ WIDOWED: __________

The purpose of this list is to identify the different roles you perform. The list presents 10 roles and defines each
of them.
PART ONE.
Next to each role indicate with a check mark if you had that role in the past, if you have that role in the present
and if you plan to have that role in the future. You can check more than one column for each role. Example: if
you offered volunteer services in the past, you do not offer them now, but plan to offer them again in the future,
you would mark the past and future columns.

ROLE PAST. PRESENT. FUTURE.

STUDENT: Attend school full time.
EMPLOYEE: Full-time or part-time employee
VOLUNTEER: To offer services without being paid,
either in cash or in kind.
to a hospital, school, community, political group, etc., at
least once a week.
CARE PROVIDER: Have the responsibility for
childcare, wife/husband, relative or friend, so
At least once a week.
HOUSEHOLDER OR HOUSEWIFE: Have
responsibility for housekeeping tasks.
House cleaning or yard cleanup, at least once a week.
Week.
FRIEND: Spending some time and/or performing some
activity with
a friend, at least once a week.
FAMILY MEMBER: Spending some time and/or
performing some activity with a family member such as
Children, wife/husband, parents or other relative, at least
1
once a week.
ACTIVE MEMBER OF A RELIJIOUS GROUP:
 Participate in and
Engage in religiously affiliated groups or activities at
least once a week.
Hobby: To participate and/or be involved in a hobby or
pastime such as sewing, playing an instrument, etc.
Sports, theater, woodworking or club membership
or equipment, at least once a week.
PARTICIPATING ORGANIZATIONS: Participate in
Organizations such as Lions Clubs, American Legion,
Weight Watchers, Alcoholics Anonymous,
Professional associations, etc., at least once a year.
week.
OTHER ROLES:
Any other role in which you have previously performed
which
You perform now or plan to perform. Write the role in
the
Blank line and mark the appropriate columns.
PART TWO.
The above roles are listed in this part. Next to each role, check the column that best indicates how valuable and
important that role is to you. Check one answer for each role even if you have had it or plan to have it.

ROLE Not very With some Very

Valuable Value and/or valuable
and/or Importance And/or
Important. Important
.
STUDENT: Attend school full time.
EMPLOYEE: Full-time or part-time employee
VOLUNTEER: To offer services without being paid,
either in cash or in kind.
to a hospital, school, community, political group, etc., at
least once a week.
CARE PROVIDER: Having the responsibility for
childcare, wife/husband, relative or friend, therefore
At least once a week.
HOUSEHOLDER OR HOUSEWIFE: Have
responsibility for housekeeping tasks.
House cleaning or yard cleanup, at least once a week, at
least once a year.
Week.
FRIEND: Spending some time and/or performing some
activity with
a friend, at least once a week.
FAMILY MEMBER: Spending some time and/or doing
 some activity with a family member such as
Children, wife/husband, parents or other relative, at least
1
once a week.
ACTIVE MEMBER OF A RELIJIOUS GROUP:
Participate in and
Engage in religiously affiliated groups or activities at
least once a week.
Hobby: To participate and/or be involved in a hobby or
pastime such as sewing, playing an instrument, etc.
Sports, theater, woodworking or club membership
or equipment, at least once a week.
PARTICIPATING ORGANIZATIONS: Participate in
Organizations such as Lions Clubs, American Legion,
Weight Watchers, Alcoholics Anonymous,
Professional associations, etc., at least once a year.
week.
OTHER ROLES:
Any other role in which you have previously performed
which
You perform now or plan to perform. Write the role in
the
Blank line and mark the appropriate columns.

SUMMARY OF THE LIST OF ROLES.

NAME: _____________________________AGE: ____________DATE: _______

SEX: ___________________ARE YOU RETIRED: _______________________

MARITAL STATUS: ________SINGLE: ______MARRIED: ______ SEPARATED: ____

________ DIVORCED: ________________ WIDOWED: __________

ROLE Perceived Assigned Value.

Incumbencies. None. Some. Much
Past. Present. Future.
STUDENT:
WORKER:
VOLUNTEER:
CARE PROVIDER:
HOUSEHOLDER OR HOUSEWIFE:
FRIEND:
FAMILY MEMBER:
ACTIVE MEMBER OF A RELIGIOUS
GROUP:
AFFICIATE:
PARTICIPANT OF ORGANIZATIONS:
OTHER ROLES:

Comments:

Signature of Therapist.

Based on the "Role Checklist", copyright, 1981 by French Oackley M.S. OTR/L Occupational
Therapy Service, Department of Rehabilitation Medicine, Clinical Center, National Institute of
Health.
Translated by Elsa Mundo OTR/L 1985.
Occupational self-assessment.

OCCUPATIONAL SELF-ASSESSMENT. MYSELF

 STEP 1: Below are statements about things you STEP 2: Now, for each statement, circle how STEP 3: Choose four aspects about
do in your daily life. For each statement, circle important it is to YOU. yourself that you would like to
how well you do. If an item does not apply to change. Place a "1" next to the most
you, discard it and move on to the next item. important, a "2" next to the second
most important and so on, a "3" or a
"4".
I have a I do this I do this This is not This is This is I would like Use the space below
problem in an well. so important extremely to change... to write comments
doing acceptabl important to me. important and ideas you have
this. e way. to me. to me. about any state.
Concentrate on my
Tasks.
Physically do what I
need to do.
Taking care of the
place where
Alive.
Taking care of myself.
Caring for others from
Who I am responsible
for.
To get where I need to
go.
Manage my finances.
Manage my basic
needs
(food, medicine).
Express myself with
others.
Get along well with
others.
Identify and resolve
Problems.
Relax and enjoy.
Complete what
I need to do.
Have a routine
Satisfactory.
Manage my
responsibilities
Be involved as a
student, worker,
volunteer and/or
family member.
Doing the activities I
like.
Work with respect to
 my personal goals.
Making decisions
Based on what I
I think it is important.
Carry out what I plan
to do.
Using my skills
effectively

ENVIRONMENTAL ASSESSMENT.

STEP 1: Below are statements about your STEP 2: Now, for each statement, circle how STEP 3: Choose 1 or 2 aspects
environment (where you live, work, or go to important this aspect of the environment is to YOU. about your environment that you
school). For each statement, mark with a circle would like to change. Place a "1"
how it is for YOU. If an item is not applicable next to the most important, a "2"
to you, discard it and move to the next item. next to the second most important
and so on, a "3" or a "4".
 This is a Is this This This is not This is This is I would Use the space
problem. accep is so important extremely like to below to write
table fine. important to me. important change... comments and
to me. to me. ideas you have
about any state
or situation.
The place to live
and take care of
myself.
The place where I
can be productive
(work, study,
volunteer).
The basic things I
need to live and
take care of
myself.
The things I need
to be productive.
People who
support and
encourage me.
People who do
things with me.
Opportunity to do
things that I value
and like.
Places where I
can go and enjoy.

LEVELS OF INTEREST IN ACTIVITIES.

Name ______________________________________________________ Date _________________

Directions: For each activity, check all columns that describe your level of interest in that activity.

What has been your level of interest? Do you Would you

participate like to
Activity currently in to be carried
out in it
In the last In the last year. This activity? Future?
10 years.
Much Little None Much Little None Yes. No. Yes. No.
Practice gardening.
Sewing.
Playing cards.
Speak / read foreign
languages.
Participate in
ecclesiastical activities.
Listening to the radio.
Walking.
Car repair.
Writing.
Dancing.
Playing golf.
Playing / watching soccer.
Listen to popular music.
Putting together jigsaw
puzzles.
Celebrate holidays.
Watch movies.
Listening to classical
music.
Attend lectures /
conferences.
Swimming.
Play Bowling.
Visiting.
Repairing clothes.
Play checkers / chess.
To roast.
Read.
Travel.
Going to parties.
Practicing wrestling.
Cleaning the house.
Playing with assemblable
games.
Watching television.
Going to concerts.
Making ceramics.
Pet care.
Camping.
Washing / ironing.
Participate in politics.
Play board games.
 Decorating interiors.
Belonging to a club.
Singing.
Being scouts.
Window shopping /
clothes shopping.
Going to the hairdresser.
Bicycling.
Watching a sport.
Bird watching.
Go to car races.
Fixing up the house.
Exercise.
Hunting.
Work in carpentry.
Play pool.
Driving.
Child care.
Playing tennis.
Cooking.
Play basketball.
Studying history.
Collecting.
Fishing.
Studying science.
Making leather goods.
Shopping.
Taking photographs.
Painting.
Making ceramics
Others...

Adapted from Matsutsuyu (1967) by Scaffa (1982).

Modified from Kielhofner and Neville (1983) NIH OT 1983.
Modified and translated by Elsa Mundo OTR/L (1985).
Reviewed by Elsa Mundo OTR/L (1985).
 THE LEVEL OF INTEREST IN PARTICULAR ACTIVITIES.
Nombre ____________________________________________________________________________

Directions: For each activity, indicate (V) all columns to which you describe your level of
interest in this particular activity.

Level of Interest.
Activities Strong Interest. Some Interest. No Interest.
Practice gardening.
Sewing.
Playing cards.
Speak / read foreign languages.
Participate in ecclesiastical activities.
Listening to the radio.
Walking.
Car repair.
Writing.
Dancing.
Playing golf.
Playing / watching soccer.
Listen to popular music.
Putting together jigsaw puzzles.
Celebrate holidays.
Watch movies.
Listening to classical music.
Attend lectures / conferences.
Swimming.
Play Bowling.
Visiting.
Repairing clothes.
Play checkers / chess.
To roast.
Read.
Travel.
Going to parties.
Practicing wrestling.
Cleaning the house.
Playing with assemblable games.
Watching television.
Going to concerts.
Making ceramics.
Pet care.
Camping.
Washing / ironing.
Participate in politics.
Play board games.
Decorating interiors.
Belonging to a club.
Singing.
Being scouts.
Window shopping / clothes
shopping.
Going to the hairdresser.
Bicycling.
Watching a sport.
 Bird watching.
Go to car races.
Fixing up the house.
Exercise.
Hunting.
Work in carpentry.
Play pool.
Driving.
Child care.
Playing tennis.
Cooking.
Play basketball.
Studying history.
Collecting.
Fishing.
Studying science.
Making leather goods.
Shopping.
Taking photographs.
Painting.
Making ceramics
Others...

Volitional Questionnaire Form. (Multiple Observation).

Client: Location:
Age: Therapist:
Diagnosis: Date:
Area to be evaluated: Scale of Score
P= Liabilities D= Doubtful. I= Involved E=Spontaneous
1st Session 2nd Session 3rd Session 4th Session 5th Session
Date. Date. Date. Date. Date.

1. Show curiosity.
2. Initiate actions / tasks.
3. Try new things.
4. Show pride.
 5. Seek challenges.
6. Seek additional responsibility.
7. Try to correct errors.
8. Attempts to solve problems.
9. Try to support others.
10. Shows preference.
11. Involve others.
12. Perform activities to
completion/achievement.
13. Stay involved.
14. It is vital / energetic.
15. Indicates objectives.
16. Shows that an activity is special
or significant.
Total Score.
P=1 D=2 I=3 E=4
Comments:

The Scoring System consists of a 4-point scale.

(4) Spontaneous:
Demonstrates the indicator without support, structure or stimulation. No support,
structure, stimulation is given to the person by the therapist throughout the entire performance time.
This score implies that the behavior stems from the person and is independent of any external factor
(e.g., therapist assistance, structure or stimulation).

(3) Involved:
Demonstrates the indicator as a minimum degree of support, structure or
stimulation.
Minimal support, structure or stimulation means that the person needs some attention, emotional
support, verbal cues, or structuring of the environment by the therapist.
Minimal support refers to the sporadic or low intensity of support needed. For example, the person
may need to be close to peers or therapist in order to demonstrate the desired behavior. This score
implies that support may be necessary for a person with adequate volition. It's probably the kind of
support given every day when someone is trying something new.
(2) Doubtful:
Demonstrates the indicator with maximum support, structure or stimulation.
Maximum support means that verbal cues have to be repeated several times, multiple visual cues are
necessary, and/or frequent intervention, such as repeated demonstration, actively engaging with the
person, are necessary for the person to initiate the desired behavior. This score implies concern about
the person's self-confidence or sense of effectiveness.

(1) Liabilities:
Does not demonstrate the indicator even with support, structure or stimulation.
The person does not show behavior even with support, structure, stimulation from the therapist. This
score implies the conclusion that there is a Volitional deficit / e.g., very low self-esteem, high anxiety
with novelty, very low interest with the environment, etc.

7. N/A Circumstances did not allow for any opportunity to evaluate.

VOLITIONAL QUESTIONNAIRE FORM (SINGLE OBSERVATION).

Client: Location:
Age: Therapist: Date:
Diagnosis: Session (Circular). 1 2 3 4 5
Area to be Evaluated. Scoring Scale.
P= Liabilities. D=Doubtful. I=Involved.
E=Spontaneous.
Scoring Scale. Comments
1. Show curiosity.
2. Initiate actions / tasks.
3. Try new things.
4. Show pride.
5. Seek challenges.
 6. Seek additional responsibility.
7. Try to correct errors.
8. Attempts to solve problems.
9. Try to support others.
10. Shows preference.
11. Involve others.
12. Perform activities to
completion/achievement.
13. Stay involved.
14. It is vital / energetic.
15. Indicates objectives.
16. Shows that an activity is special or
significant.
Total Score P=1 D=2 I=3 E=4

Activity Analysis Protocol.

Activity analyzed.
Average time required to complete it.
Average number of sessions required to complete it.
Brief description (including criteria for determining success).

Characteristics of the activity. Explanation.

A. MOTORS.
1. Position.
a. Activity.
b. Patient / Client.
2. Components of the movement(s).
a. Articulations that participate.
b. Movement(s) involved.
3. Muscles used.
4. Direction of resistance.
Required skills Grade Can the activity
be graded?
 High How?
Medium
low.
5. Action rather than position.
6. Repetition of movement(s).
7. Rhythm development.
8. Maintained contraction (static).
9. Manual dexterity.
10. Gross motor skills.
11. Fine motor skills.
12. Bilateral.
13. Unilateral.
14. Resistance.
15. Performance speed.
16. Degrees of adaptability.
a. Arc of motion (R.O.M.).
b. Resistance.
c. Coordination.
d. Substitution.

B. SENSORY.
1. Visual.
2. Auditory (presence).
3. Gustative.
4. Olfactory.
5. Tactile.
a. Material temperature.
b. Texture of the material.
c. Surface hardness to the touch.

C. COGNITIVES.
Organizational skills.
2. Problem solving skills.
a. Planning.
b. Trial and error.
3. Logical thinking.
4. Concentration.
5. Average attention.
6. Written / oral directives /
demonstration.
a. Complex.
b. Simple.
7. Reading.
8. Series.
9. Interpret signs and symbols.
10. Multiple processing / steps involved.
 11. Creativity.
12. Use of imagination.
13. Establish goals and means to achieve
them.
14. Causal relationships involved
(perception
of cause and effect).
15. Concentrate.
16. Perception of the point of view of
others
people.
17. Reality assessment.

D. PERCEPTUAL.
Sensory integration required.
2. Differentiation.
a. Figure - Background
b. Spatial relationships.
c. Proof of object.
d. Kinesthesia.
e. Proprioception.
f. Sterognosis.
g. Form constancy.
h. Color perception.
i. Auditory perception.
3. Touch integration.
4. Motor planning.
5. Bilateral integration.
6. Body outline.
7. Vestibular.

E. EMOTIONAL.
Passive or aggressive movement.
2. Destructive.
3. Gratuity.
a. Immediate.
b. Delayed.
4. Structuring.
5. Destructuring.
6. Allows control.
7. Possibility of success / failure.
8. Independence.
9. Dependency.
10. Symbolism involved.
11. Reality assessment.
12. Management of feelings.
 13. Impulse control.

F. SOCIAL.
Interaction required.
2. Isolated activity.
3. Group activity.
4. Competition.
5. Responsibility required.
6. Necessary communication.
7. Work in small groups.
8. Work in large groups.
9. Work with another person.
10. Reality assessment.
11. Control - procurement.
12. Follow-up - cooperation.

G. CULTURAL.
Personal relevance.
a. Value systems.
b. Life situations.

H. COMMON TO ALL.
1. Age Appropriate.
2. Safety precautions and hazards.
3. Sexual identification.
4. Required space.
5. Necessary equipment
6. Vocational application.
7. Cost.
8. Adaptability.
 THE DEVELOPMENT OF PLAYFUL BEHAVIOR: ATTITUDES AND ACTIONS.

Stage 1 Stage 2. Stage 3.

PLAYFUL
ATTITUDE.

Characteristics.  Stimulated attention.  Maintains interest.  Interest in the action.

 Stimulated curiosity.  Feel pleasure.  Pleasure in action.
 Interest stimulated.  Desire for initiative.  Initiative.
 Desire to know.  Desire for exploration.  Humor.
 Desire to do.  Imagination.
 Spontaneity.  Spontaneity.

Components  Feeling of  Feeling of control of  Feeling of dominance.

Safety. Objects.
Emotional.  Communication of the  Communication of needs.
 Needs.  Expression of feelings.
 Beginning of autonomy.  Autonomy.
 Decision making.
 Self-esteem.

LUDIC ACTION.

Components:
 Sensory.  Watch.
 Play.
 Smell.
 Take to the mouth.
 Moves.

 Engine.  Play.  Grasp / Release.  Uses tools (pencil, scissors,

etc.).
 Moves.  Open / Close.  Uses various objects.
 Holds in position.  Throwing / Catching.  Combines several actions.
 Emptying / Filling.
 Stacking.
 Transport.
 Change position.
 Moving from here to there.

 Cognitive.  Beginning of the  Understanding the  Imitates.

relationship relationship
Cause - effect.
Cause - effect.  It intends to.
 Beginning of the sense  To have a sense of  Creates game situation.
of permanence of the permanence of the objects.
Object.
 Uses symbols (make believe
games, drawings, language).
 Problem solving.
 Rudimentary  Understand how objects work.  Includes symbols.
knowledge of the  Generalize.
Objects.
 Problem solving.
 Understand the procedures
 for the activities.
 Memory.

 Social.  Activity with an adult.  Solitary activity.  Share materials.

 Solitary activity.  Parallel activity.  Associated activities.
 Concept of ownership.  Cooperative activities.
 Able to ask for and accept
help.
 You can help others.
 Share ideas.

Francine Ferland, Ergotherapeute

National University of Quilmes
Buenos Aires, Argentina.
August, 1997.
Translated by T.O. Mariel Pellegrini (*).
Supervised by Prof. T.O. Marta Suter (W.F.O.T.).

Authorized translation by the author to T.O. Mariel Pellegrini and her review of Prof. T.O. Marta Suter (W.F.O.T.).

EVALUATION OF PLAY BEHAVIOR

( Ferland, 1996 version).
Translated by T.O. Mariel Pellegrini (*).
Reviewed by Prof. T.O. Marta Suter.

CHILD'S NAME
SEX M F

AGE OF CHILD Year. Month. Day.

Evaluation date(s).
Date of birth.
Child's age.

PHYSICAL CONDITION OF THE CHILD:

USUAL MODE OF MOVEMENT/TECHNICAL AIDS, POSTURE

USE OF ADAPTATIONS:

ADDITIONAL INFORMATION:

 Visual impairment:
  Hearing impairment:

 Communication difficulties:

 Medication:

 Other information:

Person(s) present at the evaluation:

Total duration of the evaluation:

Interferences during the evaluation:

NAME OF OCCUPATIONAL THERAPIST:

Authorized translation by the author to T.O. Mariel Pellegrini and her review to Prof. T.O. Marta Suter (W.F.O.T.).
Evaluation of the child's general interest.

GENERAL INTEREST OF THE CHILD.

Valuation:
Interest: 0: No interest.
1: Moderate interest.
2: Marked interest. NO: Not observed.

THE HUMAN ENVIRONMENT: Level of interest. Specify.

(0 – 2)
ADULTS.
Presence of an adult.
Adult action.
Non-verbal interaction with the adult
(gestures, gestures, etc.)
caresses)
Verbal interaction with the adult.

OTHER CHILDREN.
 Presence of other children.
Actions of other children.
Nonverbal interaction with another child.
Verbal interaction with another child.

THE SENSORY ENVIRONMENT.

Visual phenomena (light, colors,...).
Tactile phenomena (textures, heat,...).
Vestibular phenomena (rocking,
hammocking,...).
Auditory phenomena (telephone, music,
others, etc.)
noise).
Olfactory phenomena (various aromas).

Assessment of interests and basic play skills.

INTERESTS AND BASIC PLAY SKILLS.

Valuation:
Interest: 0: No interest.
1: Moderate interest.
2: Marked interest. NO: Not observed.

Abilities: 0: The child cannot do the activity alone.

1: The child does the activity alone but with difficulty and not very effectively.
2: The child does the activity alone.

ACTION IN Level Level Specify:

RELATIONSHIP from from as it does, the
TO OBJECTS: Interest Skills hand using,
(0 – 2). (0 – 2). Difficulties,...
Movement: Grab / Release.
Catching an object.
Holding an object.
To strike with an object.
Release an object.
Hold an object in each hand.

IN RELATION TO THE
OBJECTS:
Change position:
 From lying down to sitting and vice
versa.
 From sitting to standing and vice versa.
Maintain the seated position.
Moving around.
Visually explore a new place.

Assessment of Interests and Basic Play Skills.

INTERESTS AND BASIC PLAY SKILLS

USE OF THE OBJECTS. Level Level Specify:

from from As it does, the
Interest Skills hand using,
(0 – 2) (0 – 2). Difficulties,...
To drink: One glass.
A bucket.
A small ball.
Screw / Unscrew.
Throw / Catch: A balloon.
One ball.
Stacking.
Emptying / Filling.
Trying to discover the properties of
objects.
Trying to find out how it works
of the objects (cause-effect relationship).
Associate objects according to their
sensory characteristics.
Combine objects to play.
Imitate simple gestures.
Use objects in a way that
conventional.
Imagine a game situation.
Finding solutions when they appear
difficulties.
Expressing feelings through
game.

USE OF THE OBJECTS. Level Level Specify:

(continued). From from as it does, the
Interest Skills hand using,
(0 – 2) (0 – 2). Difficulties,...
Interacting with others during the game:
Myself or with another child.
Use: A pencil.
One scissors.
One spoon.

SPACE UTILIZATION.
Moving around using a toy with
wheels.
To move while transporting an object.
Physically explore a new place.
Open / Close a door.
Use an elevator.

Particular interest:
Particular skills:

Particular difficulty:

Characteristics of the Playful Attitude of the Child in General.

PLAYFUL CHARACTERISTICS OF THE CHILD IN GENERAL.

Valuation:
0: Absent. 1: Occasional. 2: Present.

Characteristics: Playful Attitude. Specify.

(0 – 2).

Curiosity.

Initiative.

Sense of humor.

Pleasure.

Enjoy the challenge.

Spontaneity.

COMMUNICATION OF THEIR NEEDS AND FEELINGS.

Valuation:
0: No expression manifested. 1: Facial expressions. 2: Gestures.
3: Screams / Sounds. 4: Words / Phrases.

NEEDS. Reaction Specify.

(0 – 4).

Physiological.

Attention.

Security.

FEELINGS.

Pleasure.
Pleasure.

Sadness.

Bronca.

Fear.

Synthesis of Results.

LUDIC INTERESTS.

PLAY SKILLS.

PLAYFUL DIFFICULTIES.

INTERESTS / SKILLS.

INTERESTS / DIFFICULTIES.

SYNTHESIS OF THE RESULTS.

Interest Interest Ability Attitude Communicatio

n.
General. Playful. Playful. Playful.
Human
Environment.
 Adults / 8.
 Children. / 8.
 Sensory / 10.
Environment.
Shares.
 Objects. / 2. / 12.
 Space. / 10. / 10.
Use of:
 Objects. / 44. / 44.
 Space. / 10. / 10.
Playful Attitude. / 12.
Communication.
 Needs. / 12.
 Sentiments. / 20.

Total. / 32.

Initial Interview with Parents about their child's Play Behavior.

INTERVIEW WITH PARENTS

ON YOUR CHILD'S LUDIC BEHAVIOR (Ferland, 1994).
(1996 version).
Translation T.O. Mariel Pellegrini(*).
Prof. T.O. Review Marta Suter.

CHILD'S NAME.
M (1). F (2).
SEX

BROTHERS Number: Age:

SISTERS Number: Age:

DAYCARE (specify the Yes (1). No (2).

Type and frequency)

ETHNIC ORIGIN

AGE OF CHILD Year. Month. Day.

 Evaluation date(s).

Date of birth.

Child's age.

INTERVIEWED: Mother (1). Father (2). Other (3)

(Specify).

EVALUATOR:

DURATION OF
INTERVIEW.

Authorized translation by the author to T.O. Mariel Pellegrini and her review of Prof. T.O. Marta Suter (W.F.O.T.).
What is of particular interest to your child?

WHAT IS YOUR CHILD PARTICULARLY INTERESTED IN/ATTENTIVE TO?

Mark with an X. Specify.

VISUAL PHENOMENON.
 Image Book.
 Vivid colors.

AUDITORY PHENOMENA.
 A History.
 A Song.
 Music.
 Voice Tone.

TACTILE PHENOMENA.
 Physical Contact.

SOCIAL PHENOMENA.
 Presence of other children.
 Presence of a known Adult.

OTHERS.
 Characters.
 Comic Situations.
  Animals.
 A particular activity (e.g., emptying a
closet, opening a door).
 Other (e.g., television, light).

A) HOW DOES YOUR CHILD EXPRESS HIMSELF/HERSELF?

Rating: 0: No reaction. 1: Facial expressions.

2: Gestures. 3: Sounds / Screams.
4: Words / Phrases. 8: Don't know.

NEEDS. VALUATION. COMMENTS.

Physiological.
Attention.

INTERESTS.

FEELINGS.
Pleasure.
Pleasure.
Sadness.
Bronca.
Fear.

B) IN GENERAL, HOW YOU MAKE YOURSELF UNDERSTAND YOUR CHILD(mark

with a check mark)
cross the appropriate answer).
(1) Facial expressions.
(2) Facial expressions and gestures.
(3) Facial expressions, gestures and words.
(4) Gestures / words.
(5) Words / phrases (verbal).

WHAT IS YOUR CHILD'S LEVEL OF INTEREST IN RELATION TO:

No Interest. Moderate Interest. Marked Interest. Not Applicable. No sabe.

0 1 2 3 8

VALUATION. COMMENTS.
 LUNCH.
Food.
 Salted Foods.
 Sweet foods.
 Puree.
 Food in pieces.
 Cold food.
 Hot food.
 Try a new food.

Textures.
 Soft.
 Rough.
Substances such as.
 Snow.
 Sand.
 Water.
 Lawn.

Aromas.
To be touched.
To move or be moved in space.
Noises.

4. GAME MATERIAL.

YES. NO. N.A. (not applicable).

1 2 3

Your child plays with materials. VALUATIONS. SPECIFY.

(the material and whether
it is used
outside the home).
Of different textures.
That stimulate listening.
Stimulating to look at.
That stimulate the imitation of
 situations
common.
That stimulate the imagination.
That stimulate displacement.
That stimulate interaction with
others.

1- CHARACTERISTICS OF YOUR GAME.

Your child likes it. YES. NO. SPECIFY

if you don't know: 8.
Repeating the same game to master it.
Use new game material.
Being in a new place.
Go abroad.

Your child can.

Using the game material in ways that do not
conventional.
Imagine different ways to use play materials.
To move by oneself.

1- SUMMARIZE YOUR CHILD'S INTERESTS.

WHAT IS YOUR FAVORITE ACTIVITY?

WHAT IS YOUR LEAST FAVORITE ACTIVITY?

WHAT ARE YOUR FAVORITE POSITIONS TO PLAY?

WHAT ARE YOUR PREFERRED PLAYING PARTNERS (Choose two from each category).

Activity.
 FELLOW PLAYERS MOTHER (1).
FATHER (2).
BROTHERS / SISTERS (3).
OTHER (4).
PREFERRED PARTNERS MOTHER (1).
IN THE GAME.
FATHER (2).
BROTHERS / SISTERS (3).
OTHER (4).
1- PLAYFUL ATTITUDE.

Rating: 0: Not present. 1: Occasionally.

2: Always.

WOULD YOU SAY THAT YOUR CHILD: THESE BEHAVIORS ARE ENCOURAGED
IN YOUR FAMILY:

Valuation. A little or none at Moderately. A lot.

all.
It is curious.
It has initiative.
He has a sense of
humor.
He has fun.
Enjoy a challenge.
It is spontaneous.

TYPICAL CHILD'S SCHEDULE.

MONDA TUESDA WEDNESDA THURS FRIDAY SATURD SUNDAY

Y. Y Y DAY AY

TOMORRO
W.

AFTERNO
ON.

NIGHT.
Do you have any other information or comments to add about your child's play activities, interests or reactions?

EVALUATION OF DAILY OCCUPATIONS.

 Dream: white.  Act. From home: pink.

 Transportation: black.  Studio: light blue.
 Power supply: red.  Work: green.
 Dress: blue.  recreation: orange.
 Hygiene: yellow.  Free time: dotted.

 Last Name and First Name:  Age:

 Occupation:
 Address:
 Date:

SIGNATURE.
BAR GRAPH.

Percentages.

Occupations.
 Signature.
L.O.T.C.A.
Date: _________________
L.O.T.C.A. Battery: Score Sheet.
(Check the appropriate number).
SUB - TESTS Points. Comments.
Low. High.
ORIENTATION.
Location. 1 2 3 4
Time. 1 2 3 4
PERCEPTION.
Objects Identification. 1 2 3 4
Shapes Figures. 1 2 3 4
Overlapping Constancia. 1 2 3 4
Objects Perception. 1 2 3 4
Praxis. 1 2 3 4
VISUOMOTOR
ORGANIZATION.
Copy Geometric Shapes. 1 2 3 4
Two-Dimensional Model 1 2 3 4
Reproduction.
Construction on a Board with 1 2 3 4
Holes.
Color Block Model Design. 1 2 3 4
Design with Simple Blocks. 1 2 3 4
Reproduction of a Puzzle. 1 2 3 4
Drawing a Clock. 1 2 3 4
RATIONAL OPERATIONS.
Categorization. 1 2 3 4 5
Unstructured Riska Objects. 1 2 3 4 5
Structured Riska Objects. 1 2 3 4 5
Pictorial Sequence A. 1 2 3 4
Pictorial Sequence B. 1 2 3 4
Geometric Sequence. 1 2 3 4
Indicate: Time Spent in its Administration.
Administered in: One Session. Two or more Sessions.
Based on observation during test performance, I circle
Circle the appropriate number:
Attention and Concentration 1 2 3 4
Examinador __________________________
 EVALUATION OF FUNCTIONAL CAPACITY.

PERSONAL DATA:
NAME:
AGE:
DATE OF BIRTH: DATE:
STUDIES:
OCCUPATION:
ANALYSIS OF MOTOR FUNCTIONS. ST CT ANALYSIS OF SENSOPERCEPTIVE FUNCTIONS. S CT
T
Balance. Tactile.
Positions. Olfactory.
Articular Movement. Gustative.
Muscle tone. Auditory.
Muscular Strength. Vestibular.
Pressures. Visual.
Motor Coordination. Spatial.
Motor Organization. Temporary.
Motor Programming. Performance.
Development of Movement Patterns. ANALYSIS OF INTRAPERSONAL FUNCTIONS. S CT
T
Motor Automatism. Id.
Motor Skills. Conflict Expression.
ANALYSIS OF COGNITIVE FUNCTIONS. ST CT Expression of Emotions.
Attention. Communication.
Comprehension. Creativity.
Memory. Initiative.
Thought. Interest.
Learning. Motivation.
Trial. Spatial Organization.
ANALYSIS OF INTERPERSONAL FUNCTIONS. ST CT Temporary Organization.
Interaction. Defense Mechanism.
Role Playing Exercise. Automatism.
Group Integration. Autonomy.
Social Integration.
a) Development of Rights.
b) Development of Obligations.

GENERAL OBSERVATIONS.

VARIABLES: ST= no disorder. CT= with disorder.

Assessment of Functional Skills / A.V.D.

Patient____________________ Medical History No. ______ Date _________ Initial __ Re-evaluation __ Discharge __.
IV Functional Skills / A.V.D.
Key 7= independent. 3= moderate assistance / continuous supervision (patient plays 50% to 75%).
tooth with modified equipment/environment. 2= maximum assistance (includes dependents but can direct their care) (patient plays 25% to 50%).
tooth with distant control / supervision. 1= dependent (25% or less).
0= not applicable or the patient is not responsible for these tasks. Only selectable for certain points.
ALL MAIN ITEMS MARKED WITH BOLD SHOULD BE ASSESSED. If the skills vary within the components of the groups, the most dependent value is used for the functional level of the main
item. If this is NOT a goal, or the patient is already at the expected level, assess the goal as the functional level. Meal preparation, household chores and community reintegration can be delegated
until they can be properly addressed. In the discharge, the date and objective established should be noted in the corresponding column.

A= INCOME STATUS. G= GOAL FOR DISCHARGE. CIRCLE0 DISCHARGE STATUS.

0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7
Food. Communication.
Use of utensils. Writing.
Eating with your fingers. Telephone use.
Drinking / Sipping. Use of typewriter/computer.
Use of cup. Turn the page.
Cutting food. Open letters.
Top dress. Date.
Put on the upper part. Meal preparation.
Remove the upper part. Hot.
Up zipper. Cold.
Lower zipper. Household chores.
Lower dress. Daily cleaning.
Putting on clothes. Vacuum cleaner / Vacuum cleaner.
Removing clothes. Washing.
Set / Remove. Ironing.
Socks / Shoes / Zippers. Child care.
Hygiene for defecation and urination. Community Integration.
Garment handling. Planning.
Empty the collector. Resource utilization.
Replacement of the manifold. Money management.
Catheterization / Irrigation. Purchases.
Stimul. Digital / Coloc. Of suppositories. Safety considerations.
Hygiene. Access to the home.
Personal grooming. Driving a car.
Hand Washing / Face Washing.
Tooth brushing / dentition. Recreational Skills.
Combing / Brushing the hair. Board games.
Shaving / Makeup. Manual activities.
Putting on glasses / contact lenses. Use of radio / T.V.
Dry / Fix hair. Use of tape recorder / Phonograph.
Dental floss. Smoking.
Apply deodorant.
Ear care.
Nail care.
Bathroom. Time / Equipment considerations.
Bathroom upper limbs.
 Body bath.
Bathing of lower limbs.
Hair washing.

FIGURE 8-1. Personal care assessment, form and grading scale. Courtesy of the Department of Occupational
Therapy, Rehabilitation Institute of Chicago.

Assessment of Activities of Daily Living.

NAME:
AGE:
DATE OF BIRTH: DATE:
STUDIES:
OCCUPATION:
EVALUATION OF ACTIVITIES OF DAILY LIVING.
ACTIVITIES IN BED. I F A L P ACTIVITIES IN THE WHEELCHAIR. I F A L P
Turn to the right side. Moving forward.
Turn to the left side. Back.
Moving from supine to prone or vice versa. Rotate.
Sitting from the recumbent position. Moving from chair to bed.
Sitting upright in bed. From the chair to the toilet (high seat - regular).
Reaching for objects on the nightstand. From the chair to the bath or shower.
Turn on the light switch. Opening and closing doors.
FOOD. Moving from the standing position to the bed.
Use fork or spoon. Bath or standing shower.
Cut the meat. HYGIENE.
Drink with glass or cup. Entering and exiting the bathroom.
To be served on the plate. Washing and drying of hands and face.
DRESSED - UNDRESSED. Washing and drying of body and limbs.
Fasten with Velcro - buttons. Wash below the waist.
Fasteners - loops - belt. Nose blowing.
T-shirt. Tooth brushing.
Bodice. Combing hair.
Underpants. Cleaning and cutting your nails.
Panties. Shaving (electric - razor).
Piyama. Make-up.
Nightgown. Open and close faucets and doors.
Shirt. Handling bottles and jars.
Blouse. Use the toilet and toilet paper.
Pants. Pull the chain or press the tank button.
Dress. WRITING.
Tie. Graphic skills.
Stockings.
Shoes (buckles - laces).
Orthopedic devices.
BASIC DAILY ACTIVITIES. Taking objects from a sideboard - closet.
Placement of valves - adaptations. Peeling and cutting vegetables.
Handling of newspapers - telephone. Mix.
Winding a watch. Use whisk.
Use of eyeglasses. Cooking.
Use of money. Setting and lifting the table.
Lighting matches. Laundry (machine - manual).
 Handling of wheelchairs. Hanging clothes.
Clothes mending. Ironing.
Making the bed. Weaving.
Dust removal. Sewing (use of needles and scissors).
Use brush and shovel.

PATIENT'S TASKS AT HOME:

GENERAL OBSERVATIONS:

Signature.

VARIABLES: I= Independent (normal). F= Functional (requires supervision). A= Adaptation. L= Limited (requires assistance or help). D= Dependent.

Sensory Integration Observation Guide for 0 - 12 months. (adapted from Schaaf, Burke and
Anzalone, 1995).

Boy's name: ______________________________________ Date: ______________________

Date of Birth: __________________ Person interviewed: ___________________________
Age: _________ Interviewer: _______________________________________________________
Number of weeks of gestation: ______________________________________________________
Age adjusted: ______________________________________________________________________

Instructions: ask parents the following questions and wait for the response. It is important to know
how often the behaviors occur, so ask additional questions if necessary.

Key.

1- NEVER: the child never presents this behavior.

2- ALMOST NEVER: the child exhibits this behavior 1 to 3 times out of 10.
3- SOMETIMES: the child presents this behavior 4 to 6 times out of 10.
4- ALMOST ALWAYS: the child exhibits this behavior 7 to 9 times out of 10.
5- ALWAYS: the child always exhibits this behavior.

ONE) Does the baby like to be held and tend to mold its body to the body of the adult holding it?
(Tactile - Kinesthetic).

Additional: Does the baby arch or stiffen when held? Does it push or push back when being held?
Does it cry when it is lifted? Does it squeeze its body to the body of the adult holding it? Do you prefer
certain adults to others (your sister who has a calm temperament or your brother who is very mobile)?

Describe your baby's reactions to being held: ______________________________________

TWO) Does the baby feel comfortable when moved? ( Vestibular - Proprioceptive).

Additional: Does it become irritated when moved or when its position in space changes? Does it
tolerate being placed upside down or when moved in a circle? Do you smile when you are hammocked?

Describe your baby's reactions when movement is imposed: ___________________________

THREE) Does your baby know songs accompanied by movements? Do you recognize when others
sing them and start the movements? (Motor adaptation).

Additional: Does the baby avoid interactions with others or actively participate in them? Does he notice
when others try to interact with him?

Describe your baby's reactions when interacting with others: _______________________________

FOUR) Is your baby starting new play situations? (A.M.)

Additional: Does the baby prefer new or familiar situations? Note new toys? Do you touch and explore
toys for a period of time? Does it hit the toys? Do you use different strategies to play?

Describe your baby's play: ___________________________________________________________

FIVE) Does the baby put toys in its mouth? ( T.K)

Additional: Do you avoid putting toys in your mouth? Do you gag when you put a toy in your mouth?
When you put a toy in his mouth, does he cry? Does it bite it? Do you laugh? Are you looking for other
objects to put in your mouth?

Describe the infant's behavior when toys are placed in the infant's mouth:
_________________________

SIX) Does the baby use only his fingertips to manipulate objects? ( A.M / T.K).

Additional: When an object is placed in your hands, do you extend your fingers to drop it? Do you cry?
Do you close your hands rejecting it? Do you actively hold it (for 1 - 2 minutes)? Trying to reach it? Do
you throw it away?

Describe what the baby does with the toys: _____________________________________________

SEVEN) Does the baby use both hands together to play with toys (pass the object from one hand
to the other, cross the midline)? (A.M).

Additional: Do you use both hands to play, but not together? Does it hit toys against each other? Do
you throw them on the floor with one hand? Do you generally use only one hand to play? Do you avoid
certain types of toys that provide certain sensory input?

Describe what the baby does with its hands when a toy is offered: ________________________

EIGHT) Does the baby eat solid or semi-solid food? If yes: Do you accept a variety of textures?
(T.K).

Additional: Do you refuse food? Do you cry when offered new textures? Do you have meal
preferences?

Describe your baby's reactions to textured foods: ____________________________

NINE) Is the baby comfortable with more than one stimulus? (regulation).

Additional: Does your baby seem to "tune out" when more than one stimulus is presented
simultaneously? Or do you go to sleep? Or cry?

Describe your baby's reaction when presented with stimuli (e.g., toys, pictures): _______
TEN) Does the baby enjoy all kinds of stimuli? (e.g. music, visual, tactile)? (R).

Additional: Does your baby avoid certain textures? Do you enjoy playing with textured or soft toys? Do
you enjoy objects with strong or contrasting colors? Do you like detailed or simple figures? Do you
have difficulty determining the baby's preferences for sensory stimulation?
Describe your baby's sensory preferences: _________________________________________

ELEVEN) Does the baby change from one position to another easily (e.g., from tummy to back,
from sitting to crawling) during play? (V.M / A.M).

Additional: Does your baby prefer to be in one position and avoid moving in different positions
(especially in pronation)? Does it crash frequently? Do you cry or ask for help when you want to change
position?

Describe the baby's reactions to self-produced movement and describe the baby's movements:
_______________________________________________________________________________

TWELVE) Does your baby sleep through the night since he/she is 6 weeks old) (R).

Additional: Does your baby cry every time he/she is put to bed? Do you sleep for short periods of time
(15 minutes or less)? Do you sleep a lot? Are you awake for short periods of time (20 to 30 minutes per
day)?

Describe your baby's sleep habits: ________________________________________________

THIRTEEN) Does the baby fall asleep easily? ( R).

Additional: Does it sleep in different places such as baby seat, stroller, car seat? Can he fall asleep
without being rocked, rocked or swung (if he needs it, he demands it for more than 30 minutes)?

Describe how your baby usually falls asleep:

___________________________________________________

FOURTEEN) Does your baby calm down easily after crying or fussing? ( R).

Additional: Does your baby continue to cry when rocked or swung? Are you easily distracted when
angry? Does she continue to cry for long periods of time (an hour or more)?

Describe how your baby calms down:

________________________________________________________

FIFTEEN) Does the baby touch and explore toys with different textures? (T.K).

Additional: Do you extend your fingers to release a toy that has been placed in your hand? Does she cry
when textured toys are placed in her hand or touch her face? Do you close your hands to prevent a toy
from being placed in your hand? Do you actively hold the toy for periods of 1 or 2 minutes)?
Describe the baby's reactions when textured toys are placed in his or her hand: ____________

SIXTEEN) Does the baby like (tolerate) lying/sitting/playing on different textures (carpet, sand,
blanket, grass, water)? (T.K).
 Additional: Does your baby cry when placed on different textures? Do you stiffen your body or arch
your back in these situations? Do you extend your arms/legs when touched by any texture? Does it
withdraw its limbs at the proximity of a texture?

Describe your baby's reactions when placed on different textures: __________________

SIXTEEN) For babies over 6 months old: If the baby loses balance, do the baby's arms extend in
the right direction to protect him/her? (V.P).

Additional: Does your baby fall frequently? Do you extend your arms belatedly? Are you fearful when
you fall? Does your body arch or stiffen? When you fall, do you flex your arms and/or legs?

Describe your baby's reactions to unexpected movements: ________________________________

Questions for the interviewer:

EIGHTEEN) Comment on the father's behavior and interaction with the baby.
Briefly describe the infant's behavior and the parent's response to the different types of behavior.

NINETEEN) Do the observations contradict the information acquired during the interview?
Explain.

TWENTY) Additional comments and summary:

T.K: ( Tactile - Kinesthetic).

V.P: (Vestibular - Proprioceptive).
A.M: (Motor adaptation).
A: ( Regulation).

Sensory Rating Scale for Infants and Young Children.

From 9 to 36 months.
Child's name: _________________________
Evaluation date: ______________________
Date of birth: ______________________
 The following questions assess the degree of sensitivity that children have to different types of
stimulation. There are no right or wrong answers to any of the questions. Please circle the answer
that best describes your child.

1= Never. 2= Occasionally. 3= Sometimes. 4= Generally. 5= Always.

I. TOUCH.

Your child.
1) Does he arch his back when he is angry? 1 2 3 4 5
or excited?
2) Do you dislike being held or rocked? 1 2 3 4 5
3) Do you accept it only from 1 or 2 persons? 1 2 3 4 5
4) Do you like to be lifted up in a way that 1 2 3 4 5
Special?
5) Does it irritate you when you are touched? 1 2 3 4 5
6) Do you dislike having your face touched? 1 2 3 4 5
7) Do you dislike having your face washed? 1 2 3 4 5
8) Do you dislike having your head washed? 1 2 3 4 5
or brush it?
9) Do you dislike being dressed or undressed? 1 2 3 4 5
10) Do you dislike having your head touched? 1 2 3 4 5
11) Do you dislike being bathed? 1 2 3 4 5
12) Do you hit your head on purpose? 1 2 3 4 5
13) Do you seem to be very sensitive to food or to the 1 2 3 4 5
Water temperature?
14) Do you seem to be very aware of when you are touched? 1 2 3 4 5
15) Do you have an exaggerated response to pain? 1 2 3 4 5
16) Do you dislike crawling, or playing in the grass, 1 2 3 4 5
or in the sand?
17) Do you have difficulty transitioning to solid foods? 1 2 3 4 5
18) Do you dislike textured food? 1 2 3 4 5
19) Do you avoid foods that need to be chewed? 1 2 3 4 5
20) Do you avoid putting objects in your mouth? 1 2 3 4 5
21) Do you dislike having your hair cut? 1 2 3 4 5
22) Do you dislike cutting your nails? 1 2 3 4 5
23) Do you dislike being upside down? 1 2 3 4 5
24) Do you dislike being on your back? 1 2 3 4 5
25) Does he bite the nipples or the cup when he drinks? 1 2 3 4 5
26) Do you dislike being touched on the back of the neck? 1 2 3 4 5
27) Do you dislike using a pacifier or pacifier sucking? 1 2 3 4 5
fingers?
 28) Do you dislike being lifted alone when he or 1 2 3 4 5
they decide?
29) Do you respond slowly, or very little to pain? 1 2 3 4 5
30) Is it impressive to have no conscience? 1 2 3 4 5
to be touched?
31) Do you need to bite, suck, or chew on a 1 2 3 4 5
Pacifier or a blanket to calm down?
32) Do you dislike walking barefoot over 1 2 3 4 5
Grass, sand, carpet or the floor?
33) Do you dislike eating with your fingers? 1 2 3 4 5
34) Do you prefer to play alone and away from other children? 1 2 3 4 5
35) Do you dislike being around someone who 1 2 3 4 5
not from your family?
36) Do you like to touch others, but not to be touched? 1 2 3 4 5
For them?
37) Do you frequently push and bump into others? 1 2 3 4 5
38) Do you dislike brushing your teeth? 1 2 3 4 5
39) Do you pay too much attention to injuries? 1 2 3 4 5
40) Do you have a strong need to play 1 2 3 4 5
Objects and people?
41) Do you enjoy chewing or sucking on objects? 1 2 3 4 5

II. MOVEMENT.

Your child.
1) Does your back arch when you are moved? 1 2 3 4 5
2) Do you dislike to be rocked? 1 2 3 4 5
3) Do you dislike being cradled? 1 2 3 4 5
4) Do you dislike being lifted in the air? 1 2 3 4 5
5) Do you prefer to be held vertically? 1 2 3 4 5
With the head up?
6) Do you dislike being in the position of 1 2 3 4 5
Head down?
7) Do you dislike being turned? 1 2 3 4 5
8) Do you dislike losing your balance? 1 2 3 4 5
9) Do you walk on your fingertips? 1 2 3 4 5
10) Do you enjoy spinning or twirling? 1 2 3 4 5
11) Do you appear to be clumsy in your movements, 1 2 3 4 5
 does it crash frequently?
12) Do you swing when seated? 1 2 3 4 5
13) Do you like to jump? 1 2 3 4 5
14) Do you like being upside down? 1 2 3 4 5

III. AUDITORY.

Your child.
1) Do you respond negatively to loud sounds 1 2 3 4 5
and unexpected?
2) Do you seem to fear certain common noises such as: 1 2 3 4 5
Vacuum cleaner, mixer?
3) Does he seem to be distracted by unexpected sounds such as the 1 2 3 4 5
refrigerator?
4) Do you have difficulty emitting common sounds? 1 2 3 4 5
at your age?
5) Do you cover your ears to avoid sounds? 1 2 3 4 5
6) Do you cover your ears so as not to hear? 1 2 3 4 5
7) Do you like to make loud sounds? 1 2 3 4 5
8) Do you seem to be confused as to the direction of the 1 2 3 4 5
which comes with the sounds?
9) Do you sometimes seem not to listen? 1 2 3 4 5
10) Do you like to put your head, hands or all of your 1 2 3 4 5
Body next to devices that have vibration?

IV. VISION.

Your child.
1) Does it seem to be very sensitive to light? 1 2 3 4 5
2) Do you avoid eye contact with others? 1 2 3 4 5
 3) Does he seem to be distracted by visual stimuli? 1 2 3 4 5
4) Do you enjoy observing objects that rotate by 1 2 3 4 5
Long time?
5) Do you like to observe lights that flicker on and off for 1 2 3 4 5
Long time?
6) Do you have difficulty following objects with your eyes? 1 2 3 4 5
7) Do you cover your eyes very often? 1 2 3 4 5

V. TEMPERAMENT AND GENERAL SENSITIVITY.

Your child.
1) Does he seem irritable? 1 2 3 4 5
2) Do you have difficulty with changes in routine? 1 2 3 4 5
or with unexpected plans?
3) Do you dislike going to unfamiliar places? 1 2 3 4 5
4) Do you get very irritated in public areas such as 1 2 3 4 5
Shoppings, restaurants?
5) Did you have frequent colic as a baby? 1 2 3 4 5
6) Is it a difficult child to raise compared to 1 2 3 4 5
Other children?
7) Do you wake up a lot at night? 1 2 3 4 5
8) Do you wake up screaming or crying as a result of 1 2 3 4 5
if you were afraid?
9) Do you seem to be more sensitive than other children? 1 2 3 4 5
10) Do you have rapid mood swings? 1 2 3 4 5
11) Does he seem to be more active than other children? 1 2 3 4 5
12) Does he move a lot when he is in your arms? 1 2 3 4 5
13) Do you seem to disconnect from those around you? 1 2 3 4 5
14) Does he/she appear to be aggressive to objects or other 1 2 3 4 5
children?
15) Is he/she more demanding than other children? 1 2 3 4 5
16) Do you have difficulty trying new things? 1 2 3 4 5
17) Do you have shorter attention spans than other children? 1 2 3 4 5
at your age?
18) Do you prefer to play with whole body movements? 1 2 3 4 5
What with small objects?
19) Is the child easy to raise compared to other children? 1 2 3 4 5
Children?
20) Does he seem to be less active than other children? 1 2 3 4 5
21) Would you appear to be less sensitive to objects 1 2 3 4 5
 What other children?
22) Do you prefer to play with small objects rather than with 1 2 3 4 5
Full body movements?
23) Do you get in a bad mood when you have to change 1 2 3 4 5
of activity?
24) Do you dislike having unexpected visitors? 1 2 3 4 5

Scoring Form.
Item Subtest.
Score Score.
Scoring for items 1 - 5: 0 - Adverse. 1 - Medium defensive. 2 - Integrated.
Response to touch: arms and hands ....................................................................................______
Response to touch: belly ..................................................................................................______
Response to touch: soles of the feet ................................................................................______
Response to touch: mouth ......................................................................................................______
Response to touch: over-the-shoulder bra......................................................................... _____
Deep Touch Reaction, Subtest Score _____

Scores for items 6 a - 10a: 0 - No response. 1 - Disorganized. 2 - Partial. 3 - Organized.

Motor adaptation: adhesive tape on the hand ................................................................... ______
Motor adaptation: shoe ..................................................................................................______
Motor adaptation: toy in the womb ............................................................................ ______
Motor adaptation: paper on the face .....................................................................................______
Motor adaptation: thread around the hands ..................................................................______
Adaptive Motor Functions, Subtest Score ______

Scores for items 10b - 10b: 0 - Hyperactive. 1 - Hypoactive. 2 - Normal.

Visual - tactile: adhesive tape ...............................................................................................______
Visual - tactile: shoe ...........................................................................................................______
Visual - tactile: toy ...........................................................................................................______
Visual - tactile: paper on the face ..............................................................................................______
Visual - tactile: thread .................................................................................................................______
Visual - tactile integration, Subtest score _____

Score for item 11: 0 - No response. 1 - Integrated.

Lateralization of the eyes: tennis ball .............................................................................______

Score for item 12: 0 - Poorly integrated. 1 - Well integrated.

Visual tracking: finger puppet ........................................................................................______
Oculo-motor control, Subtest score ______

Scoring for items 13, 14a, 15a, 16, 17: 0 - Adverse. 1 - Defensive midfield. 2 - Integrated.
Response to motion: vertical plane ..............................................................................______
Response to motion: circular to the right .............................................................______
Response to motion: leftward circular ...........................................................______
Inverted: pronation ..............................................................................................................______
Inverted: supination .............................................................................................................______

Scoring for items 14b and 15b: 0 - Absence of nystagmus. 1 - Nystagmus present.
Nystagmus: right ................................................................................................................______
Nystagmus: left ..............................................................................................................______
Reaction to vestibular stimulation, Subtest Score ______
Total Score ______

Test of Sensory Function in Infants (T.S.F.I).

Administration and scoring.

Directions: add the score of each item to obtain the total of each Subtest. Transfer this score to the
profile according to the baby's chronological age.
 Profile.

Normal: N. Risk: R. Deficient: D.

Subtest. N* 4 - 6 months. 7 - 9 months. 10 - 12 months. 13 - 18 months.

N R D N R D N R D N R D
Resp. To
Touch 9-10 8 0-7 9-10 8 0-7 9-10 8 0-7 9-10 8 0-7
Deep.
Function
Motor 7-15 6 0-5 11-15 10 0-9 14-15 13 0-12 15 14 0-13
Adaptive.
Integr.
Visual 4-10 3 0-2 9-10 7-8 0-6 9-10 7-8 0-6 9-10 7-8 0-6
Tactile.
Control
Oculo 1-2 0 2 1 0 2 1 0 2 1 0
Motor.
Reaction
to the 10-12 9 0-8 10-12 9 0-8 10-12 9 0-8 11-12 10 0-9
stimulus
Vestibular.
Score
Total 33-49 30-32 0-29 41-49 38-40 0-37 44-49 41-43 0-40 44-49 41-43 0-40

Observation of Hand Skills.

(For Kindergarten and First Grade). By Mary Benbow.

Ye No Remarks.
s.
1) Separation of elbow movements:
- Evaluation of supination.
2) Forearm stability (no need to fix the forearm
to the body)
- Opening a candy wrapper.
3) Wrist stability in extension:
- Make plasticine balls between fingers 1, 2, 3.
- Paint small circles of half a centimeter in diameter.
Diameter.
4) Separation of thumbs with fingers interlocked:
- Turn the thumbs, one over the other, towards the body.
- Turn the thumbs, one over the other, from the body
outward.
5) Separation of the two sides of the hand, when the
Fingers 4 and 5 are inactive:
- Use of scissors.
- Snap your fingers.
6) Thumb - index space support:
- Hold the pencil while painting circles 1/4 cm wide.
Diameter.
- Closing of the "zipper" of a plastic bagmaker,
Pressing with thumb and fingers.
7) Separation of fingers:
- Imitation of the evaluator's fingers: (in the
Sign language: "I love you"):
One: fingers 2 and 5 extended.
Two: fingers 3 and 4 flexed.
Three: thumb in abduction.
Four: move the hand in this way to both sides.
- Ask the child to imitate the evaluator, with their
Hands at the sides of his head, palm of the hand, palm of
the
hand forward:
a: opposition of the fingers
1 - 2.
1 - 3.
1 - 4.
1 - 5.
b: opposition of the fingers
1 - 3.
1 - 5.
1 - 2.
 1 - 4.
c. Move each finger separately without
Movements in the other hand.
d. Stirring motions: (flex the thumb without moving
The index finger), 3 fingers flexed, finger 2 extended, the
Flexes and extends the thumb.
8) Arches:
- Imaginary holding of a ball (if you have difficulty),
Try it with a ball in your hand).
- Form a hole with both hands and move inside.
two cubes.
- Bring the tenar and hypothenar areas close together and
form a
groove along the hand.
9) Wrist movements:
- Threading of a cord into a cardboard with holes.
the fingers hold the cord and must be moved
from full flexion to full extension.
10) Fingertip rotation:
- Turning a pencil over (use of the distal joint)
of the fingers).
- Holding a coin and turning it in the direction of the
clockwise.

HISTORY OF DEVELOPMENT

Child's name: ________________________________ Day: _____________________

Date of Birth: _____________________________
PRENATAL HISTORY

 Previous pregnancies: number and problems: _____________________________________

 Pregnancy history with this child: medication use, mother's health, complications or problems:
______________________________________________________________
_________________________________________________________________________
 Duration of pregnancy: number of weeks, duration of labor: _____________________
 History of delivery: type of delivery, complications: __________________________________

EARLY HISTORY

 Newborn condition: weight, height, problems: ______________________________

 Feeding: method, duration, weaning, feeding patterns, problems: _________
_________________________________________________________________________
 Sleep habits: patterns, problems: _________________________________________
 Activity level: child's favorite activities, reaction to movement: _____________
_________________________________________________________________________
 Sphincter control: age, method, problems: __________________________________
 Medical history: hospitalizations, allergies, ear infections, other problems: ______
_________________________________________________________________________
 Developmental milestones: age at which the child could:
Sitting alone: ____________ Crawling: ___________ Walking: ______________
Run: _____________ Use words: __________ Combine 2 words: ________
Combine 3 words: ____________ Ask questions: ____________
Drink from a glass: ______________ Use a spoon: _________________
 Describe your overall coordination: _____________________________________________
 Describe your ability to communicate: _________________________________________
 Unusual behaviors or problems: Ex: head banging, swaying, breath holding, temper problems or
tantrums: ________________________________________

CURRENT STATUS

 Take any medication: __________________________________________________

 Type of diseases and frequency: __________________________________________
 Food: _____________________ Sleep habit: _______________________
 Activity level: ___________________ Interaction with other children: _____________
 Attends kindergarten or daycare: describe behavior, play patterns, socialization:
____________________________________________________________
 Describe your language: __________________ describe your coordination: ______________
 Problems you notice: _______________________________________________________
 Name and address of pediatrician: _____________________________________________
 Name and address of other specialists treating the child: _______________________
________________________________________________________________________

FAMILY HISTORY
 Mother's name and profession: ______________________________________________
 Mother's current marital status: _______________________________________________
 Father's name and profession: ________________________________________________
 Father's current marital status: __________________________________________________
 Family history since the child's birth: moves, traumatic situations, problems:
________________________________________________________________
 Indicate if any sibling has or has had any problems: ________________________
__________________________________________________________________________

(Translated by Lucy Miller, OTR. MMI test).

A. SENSORY HISTORY

Below you will find questions regarding how your child responds to certain types of sensory
stimuli and his or her level of performance in selected areas. Please consider all questions
carefully, answer yes or no and add comments where appropriate.
RESPONSES TO TACTILE STIMULI

To your child:
1. Dislikes having her hair or face washed _______________________________________
2. Dislikes kissing, hugging or cuddling by other parents ____________________
3. Looks irritated when grabbed _____________________________________________
4. He is eager to touch and look for rough wrestling type games ____________________
5. Dislikes wearing certain types of fabrics or clothing __________________________________
6. Dislikes short sleeves or shorts _______________________________
7. Pushes or pushes other children _______________________________________
8. Isolates from other children or adults _______________________________________________
9. He dislikes being touched unexpectedly or approached from behind ______.
_________________________________________________________________________
10. He dislikes walking barefoot ________________________________________________
11. Dislikes dirty hands ____________________________________________
12. Dislikes playing with "dirty" things, e.g. finger paint, sand, mud, etc. _______
__________________________________________________________________________
13. Distracted when others are nearby _____________________________________________
14. Prefers to touch smooth textures or hard or rough surfaces ____________________________
15. He hits his head on purpose now or in the past _______________________________
16. Pinches, bites or otherwise hurts ___________________________________
17. Tends to feel less pain than others ___________________________________________
18. Tends to feel more pain than others _____________________________________________

RESPONSES TO SOUND

To your child:
1. Dislikes unexpected or loud sounds ___________________________________
2. You need to have the directives repeated ____________________________________________
3. Distracted by most sounds _________________________________________
4. Shows confusion about the direction from which the sound comes ____________________
5. Speak very loudly _____________________________________________________
6. Has difficulty understanding or using the language ____________________________________
7. He seems to have difficulty listening _____________________________________________
8. She likes music __________________________________________________________

RESPONSES TO TASTE AND ODOR

To your child:
1. Chewing inedible objects ________________________________________________
2. Has unusual cravings for foods or odors _____________________________________
3. Dislikes particular odors ______________________________________________
4. Ignore unpleasant odors ___________________________________________________
5. Use smell as a method of exploring new objects ___________________________
6. Explore objects by putting them in your mouth __________________________________
7. Has trouble eating (choking, drooling, soiling, putting too much food in mouth)
_____________________________________________________________________
8. Dislikes foods of certain textures _______________________________________
9. Act as if all food tastes the same ____________________________

RESPONSES TO VISUAL STIMULI

Your child:
1. He seems happier in the dark ____________________________________________
2. Has difficulty keeping eyes on task or objects ________________________
3. Tilts head to one side or closes one eye to look at an object __________________
4. Rubs eyes or complains of headaches ________________________________
5. Appears sensitive to light or visual stimuli __________________________________
6. Look at objects, figures or drawings by placing them very close to your face or look at them in great
detail _____________________________________________________________
7. Resists being blindfolded ______________________________________________
8. Have a diagnosed visual impairment or wear glasses _____________________________

RESPONSES TO THE POSITION. BALANCE AND MOVEMENT

Your child:
1. Keeps your back bent when standing or sitting __________________________
2. He tires easily when playing ______________________________________________
3. Walk on tiptoes now or in the past ____________________________________
4. He prefers games in which he can play alone _______________________________________
5. Seems clumsy, falls down easily or carries things away _______________________
6. Seems uncoordinated or has difficulty learning new movements ________________
__________________________________________________________________________
7. Is sensitive to movement (gets motion sickness easily or breaks down when traveling in a car)
__________________________________________________________________________
8. He likes to swing and/or play in the amusement park, around the world, merry-go-round, etc.
__________________________________________________________________________
9. He likes to climb and play on the playground equipment at
___________________________________.
10. Prefers to play indoors rather than outside or in the playground with other children
_______________________
11. Likes to be thrown in the air _________________________________________________
12. He likes to swing on the spot, now or when he was a kid ____________________________
13. Likes to spin like a top, jump, hop, skip, etc. more than other children ______________
14. It is in constant motion, all the time jumping _____________________________
15. Has difficulty using or appears to be unaware of a part of his or her body _________
16. Has difficulty controlling small manipulative toys ______________________
17. Has difficulty learning to hold a pencil or crayon with a three-fingered posture (thumb, index and
middle fingers) ______________________________________________________
CONDUCT

Your child:
1. He seems to be generally happy _____________________________________________
2. Seems restless and hyperactive most of the time ________________________________
3. Seems to be resting or distracted ___________________________________________________
4. Is aggressive with others or easily angered ______________________________________
5. Easily distracted ________________________________________________________
6. Cries or gets frustrated easily __________________________________________________
7. You have unusual fears ______________________________________________________
8. You are bothered by changes or unusual events _____________________________________
9. Often has temper tantrums or sudden changes in temper ______________________
10. Difficulty separating from mom or dad _________________________________
11. Has difficulty learning new things ______________________________________

OTHER
Please add any additional information that you consider useful for a better understanding of your child:

(Translated and adapted from Ayres, Royeen, Oetter, Wilbarger, et al.)

B. CLINICAL OBSERVATION

ADDITIONAL INFORMATION
The following clinical observation has been helpful in assessing the client's sensory-integrative and
practical functions.
This includes reactions and functions that can be observed during the evaluation or in other situations
and places such as the therapeutic environment, the classroom, the square and at home. Parents and the
teacher can also provide information.
The following list provides a brief description of the observation and, where possible, some comments
about its relevance to the areas of function tested by SIPT. The observations in this list were clinically
used by therapists for many years. However, research related to normative expectations and a
relationship between these functions and test scores is limited, so it is suggested that therapists use this
information only for the purpose of feeling comfortable at their particular level of experience and
clinical judgment.
Experiencing assessment and observation of normal clients is invaluable and provides a framework for
judging performance during clinical observation of neuromotor behavior.

ASSOCIATED MOVEMENTS: strange movements of the client's mouth or involuntary movements in

the contralateral extremities while performing an activity may appear to be "mirror movements".
The associated movements normally increase as the effort required by the activity is increased. It may
also indicate a delay in neuromuscular maturation.

CO-CONTRACTION: see proximal joint stability.

BODY LINE CROSSING: the ability to cross the midline of the body with one or both hands for the
purpose of manipulating objects in a contralateral space. Deficits in this area may be associated with
inadequate bilateral integration or poor trunk rotation.
It may also be an indicator of a deficit in the development of manual preference.

DISTRACTIBILITY: the tendency to pay attention to extraneous stimuli in the environment and makes
it difficult to pay attention to activities. Distractibility has been associated with some disorders in
sensory modulation (including tactile defense) and increased activity levels.

BALANCING AND STANDING REACTIONS: Balancing reactions are compensatory movements of

different parts of the body that serve to maintain the center of gravity over the support base whenever
the center of gravity or the support surface is displaced.
Straightening reactions are used to achieve or recover these postures. These reactions are related to
visual, vestibular, proprioceptive function.
Deficits in vestibular proprioceptive functioning are more noticeable when there are balance difficulties
or when these are increased by occluded vision.

FINGER TO NOSE: with eyes closed and arms outstretched at the sides of the body at shoulder height,
the client is asked to touch his or her nose alternately first with the index finger of one hand, then
extending the arm again and then doing the same with the index finger of the other hand. This is a
common neurological test that checks brain integrity.
If difficulties appear, they may be related to deficits in proprioceptive processing associated with a poor
body schema.

HYPERSENSITIVITY TO GRAVITY: (gravitational insecurity) The client shows exaggerated

reactions of fear, anxiety or distress in response to changes in head position or a shift in the center of
gravity (their reactions are out of proportion to the threat of the moment).
This response is considered to be a disorder of sensory modulation related to vestibulo-proprioceptive,
reticular or limbic functioning; a lack of inhibition of these systems may also be involved.

HYPERSENSITIVITY TO MOTION: (negative response to motion) The client exhibits autonomic

nervous system responses (such as nausea, vomiting, vertigo) in reaction to rotation or linear
acceleration or deceleration. It is theorized that this type of response is related to poor inhibition of
vestibular information. This response may also be a type of disordered sensory modulation.

HYPERSENSITIVITY TO TOUCH: (tactile defensiveness) The client responds to passive, unexpected

and/or gentle touch with exaggerated emotional reactions with increased activity levels and/or other
behavioral problems (such as aggression). The observation and reporting of these reactions is believed
to be related to some inefficiency in the sensory-tactile process. Tactile, reticular or limbic defense is
considered. A lack of inhibition of the sensing process in these systems may also be involved.

HYPOSENSITIVITY TO MOVEMENT: the client does not respond to movement with the usual
reactions of dizziness or other physiological changes. The presence of hyposensitivity to movement may
suggest some inefficiency in the processing of vestibular sensory input.

HYPOREACTION TO TOUCH: the client shows a low response to touch, pain or temperature in cases
where a reaction would normally be expected. This behavior is considered to be associated with poor
tactile input processing. When this occurs in conjunction with tactile defensiveness, it is related to a
disorder of sensory modulation related to tactile, reticular or limbic functioning.

HYPOTONIA: exaggerated joint motility (hyperextension joint laxity) and/or palpation of "soft"
muscles may be indicators of hypotonia. The vestibular and proprioceptive systems are related to
muscle tone, especially extensor tone. Flexor muscle hypotonia may be associated with poor tactile
processing and somatodyspraxia (hypotonia is not associated with sensory integration disorders).

INCREASED ACTIVITY LEVEL: unusually high levels of motor, and sometimes verbal, activity that
occur in different situations. Increased motor activity has been associated with tactile defensiveness and
other disorders of sensory modulation.

POSTURAL ADJUSTMENTS: (background movements). Spontaneous postural adjustments that

facilitate hand movements, such as that observed when reaching for distant objects. The unconscious
acquisition of the need for compensatory postural adjustments depends on the integration of vestibular-
propioceptive stimuli.

PROJECTED ACTION SEQUENCES: the ability to plan and produce anticipatory action sequences.
Anticipatory or projected action sequences are those in which the objective must be formulated and the
action plan developed before the movement has been initiated. This ability, especially when it includes
bilateral movement patterns, is related to vestibulo-propioceptive processing and sequential praxia.
Examples of tasks that evaluate this function:
 Jump in a series of squares or circles on the floor.
 Tackle a ball whose trajectory cannot be anticipated.
 Kicking a rolling ball.
 Running, jumping or walking on a rolling object.
Projected action sequences can also be observed during a variety of therapeutic activities. The demands
increase if the client and the object are in motion; and decrease if they are stationary. A critical
component of the quality of performance is that the customer performs the required action without
hesitation, stopping and correcting the planned action once it has been initiated.

PRONATION EXTENSION: the ability to simultaneously elevate the head, flex the arms, elevate the
trunk, and extend the legs against gravity in the ventral decubitus position. Poor pronation extension is
associated with inadequate processing of vestibulo-proprioceptive stimuli.

PROTECTIVE EXTENSION, SUPPORTING REACTION: a protective reaction results from loss of

balance and includes extension of the non-weight-bearing limbs (those on the side where the fall may
occur). A support reaction is characterized by the extension of the weight-bearing limbs. Poor and
immature responses may help identify poor vestibulo-propioceptive function.
However, protective extension and supportive reactions develop in the early years of a child's life and
may not be impaired in clients with sensory integration dysfunction.
PROXIMAL JOINT STABILITY: the ability to stabilize the proximal joints can be observed by asking
the client to assume the quadruped position, making sure that he/she understands the desired position.
Observe the lack of ability to stay in that position without locking the elbows, scapula flapping or
lordosis of the trunk. This poor postural ability may be associated with poor vestibulo-proprioceptive
processing and poor extensor muscle tone. In the past, the ability to stabilize joints was erroneously
equated to the simultaneous co-contraction of antagonist muscles around a joint. While the ability to co-
contract muscles may be an element of postural stability, co-contraction generally does not occur under
normal conditions of joint stabilization.

LONG RECIPROCAL AND JUMPING LONG JUMP: this activity includes bilateral, reciprocal,
alternating or symmetrical limb movements. The client is asked to perform the actions by imitating the
examiner. The ability to perform these tasks after examiner demonstration and practice on one attempt
has been associated with difficulties in bilateral integration and sequential praxia.
SLOW MOVEMENTS (RAMP): is a common neurological test to evaluate the integrity of the
cerebellum. The client abducts the arms to shoulder height and touches the shoulders with his hands.
Imitating the examiner, the client slowly extends his arms until they are fully stretched to shoulder
height and then slowly returns his hands to his shoulders.
A round-trip sequence should take approximately 5 seconds.
The appearance of segmentation or other irregularities may be related to some deficit in proprioceptive
processing associated with poor body schema.

SUPINATION FLEXION: simultaneous flexion, against gravity, of knees, hips, trunk and neck in the
dorsal decubitus position; the upper portion of the head should approach the knees. The ability to
position oneself in this position may be related to somatosensory function and praxias.

Translated by T.O. Julia Salzman, from International Sensory Integration material.