1
Clinical Observations
(Describe the quality of each task. Highlight the items you will test before you start)
Student: _________________________________ Age: ______ Date: ____________
Classroom Skills
Task
Quality of Task
Pencil grasp
Tripod Other:
Pressure
! Light
! Adequate
! Hard
Hand dominance
! Right
! Left
Identify letters/numbers
Pre-tracing
Tracing/Cutting
Design imitation
Design a copy
Draw a person
Handwriting sample
write your name
Copy
Dictate
Self -generate
Write letters/numbers
Coloring
Design copy
2
Task
Quality of Task
Cutting
Quality of scissors grasp
Thumbs
! Up
! Down
Hand
! Right
! Left
Help with positioning
! Yes
! No
Picture Assembly
Supporting Skills
Vision
Quality of Skill
! Smooth
! Non-smooth
! Midline shift
! Convergence
! Divergence
Right / Left Discrimination
On-self: ! Yes ! No
Off-self: ! Yes ! No
Manual Muscle Testing. (key: s = strong f = functional • w = weak)
Muscles
Side
S
F
W
Side
S
F
W
Shoulders
Right
Left
Elbows
Right
Left
Wrists
Right
Left
Thumbs
Right
Left
Fingers
Right
Left
Pinch
Right
Left
Comments about Muscle Testing:________________________________________________
_______________________________________________________________________
3
Finger Coordination
Task
Right / Left
Quality of Skill
Finger touching
! Right
! Left
Grandma’s glasses
! Right
! Left
Chickens
! Right
! Left
Butterflies
! Right
! Left
Finger Coordination-Dominant Hand
Task
Quality of Skill
Rotation
Translation
Shift
Squirreling
Graphesthesia/Tactile Processing: __________________________________________
______________________________________________________________________
Gross Motor Skills
Task
Quality of Skill
Stand on one leg
! Eyes open secs ! Eyes closed secs
Jumps
Both feet
! Yes
! No
Hops
Gallops
Skips
Jumping Jacks
Supine flex (egg)
Seconds:
Prone ext. (airplane)
Seconds:
Plank
Seconds:
4
General muscle tone
! Low
! Average
! High
Muscle tone in hands
! Low
! Average
! High
Crossing midline
Prop/kinesthetic/body awareness
Identify Body Parts
Head, hair, eyes, nose, mouth, chin, arms, hands,
fingers, wrists, elbows, legs, knees, toes
Personal Care and General Observations
Task
Quality of Skill
Dressing
Feeding/use of utensils
Grooming/toileting
Direction-following (three-step/overall)
Affect/attitude/arousal level
Interests/Strengths
Overall impression(s): _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________