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OT Checklist
Could your child benefit from OT?
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Occupational Therapy Referral Checklist
Gross Motor
Slumps in chair
Fidgety in chair
Muscles appear weak/floppy
Tires easily (difficulty finishing assignments)
Hold head up with hand
Leans on things when standing
Clumsiness
Poor coordination with activities such as running, skipping or hopping
Bilateral Integration
Switches hands during writing
Difficulty adjusting paper when writing
Poor stabilization of paper when writing
Keeps work on one side of desk
Switches hands during fine motor tasks
Poor manipulation of dressing fasteners
Difficulty tying shoes past age 5
Difficulty with bookbag/pencil sharpener/shoes
Fine Motor
Awkward grasp on pencil/scissors
Drops things easily
Experiences hand fatigue/pain
Poor isolation of fingers on keyboard
Tremors when writing/cutting
Writing pressure too light/heavy
Has difficulty with writing/cutting
Excessive hand perspiration
Writing not fluid/not legible
More difficulty than peers with writing/coloring/cutting
Sensory Processing
Avoids or has difficulty with eye contact
Seems not to understand what was said
Seems reluctant to participate in sports/games
Prefers to touch rather than be touched
Avoids getting hands messy
Seems more sensitive to pain than others
Complains that others push him/her
Difficulty making friends
Has strong desire for routines/sameness
Has strong outbursts of anger/frustration
Bumps into things frequently
Falls out of chair
Seems to deliberately fall or tumble
Is easily distracted by visual stimulation
Seems overly sensitive to sounds
Unable to follow 2-3 directions
Often seems overly active
Hits or pushes other children
Mouths clothing/objects frequently
Tends to prefer to play alone
Intense and easily frustrated
Lacks carefulness/impulsive
Moves in/out of chair while working
Distracted by noise and/or movement in the environment
Seems clumsy
Visual Motor
Poor letter recognition
Poor letter/word spacing and/or alignment
Difficulty completing reading/writing tasks
Letter/word reversals (past 1st grade)
Difficulty staying on the line when cutting
Eyes watering/rubbing/squinting
Poor letter formation
Inaccurate or slow copying/reading (loses place, omits words, adds words)
Unable to accurately draw a person
Difficulty coloring within boundaries
Poor spelling skills
Poor alignment of numbers in math
Difficulty with copying
Does not recognize or fix errors well
Motor Planning
Difficulty following multi-step motor tasks
Difficulty initiating tasks
Difficulty learning new tasks
Often tries to imitate others
Performance of tasks is slow
Poor task completion
Poor organizational skills
Does poorly on timed tests
Describe your child's strengths and weaknesses. List any goals you have.
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