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A P P E N D I X A

An Evaluation: Early Intervention Physical Therapy Evaluation

PHYSICAL THERAPY

General Information:
Child’s name: male female
Exam date:
Parent’s names:
Address: Phone:
Date of Referral:

Date of Birth: Chronological Age:

Medical diagnosis:
Precautions:
Medications:
Pediatrician:
Other health care services/agencies:

Medical and Birth History:

Other EI services:

Parent’s concerns and priorities:

Systems Review:
Child’s current height: weight:

Communication: verbal non verbal vocal sign

Device:

Vision: WFL: Impaired:

Hearing: WFL: Impaired

Emotion/behavior during exam: cooperative uncooperative passive other:

Motor control: impaired not impaired
Motor learning: impaired not impaired

190
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Chapter 6 ■ Providing Services in an Early Intervention Program 191

Sensation to touch : impaired not impaired

Oral motor skills: impaired not impaired

Additional comments:

Caregiver availability and capability:

Lives with mom who is primary caregiver
Other:
Also attends daycare center. Staff:

Tests and Measurements:

Range of Motion and Muscle Tone

Range of motion and muscle tone are WNL throughout the trunk and extremities
Range of motion and muscle tone are WNL throughout the trunk and extremities with the following
exceptions:

Functional Strength
Able to touch the back of the head
Able to touch the middle of the back
Able to pronate/supinate the forearm
Able to oppose fingers to thumb
Able to rise from a chair
Able to step up a six-inch step

Rises from the floor:

using half kneel
via squat
via modified plantargrade
requiring: assist
Other:

Neuromotor development

Reflexes: Primitive reflexes appear integrated are present

Comments:

Reactions: Righting
Protective extension

Equilibrium: prone supine quadruped sitting kneeling standing

Balance: not impaired impaired
Sitting:
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192 Part II ■ Practice Settings

Standing:
Walking:
During ADLs:

Coordination: UE: not impaired impaired

LE: not impaired impaired

Mobility:

Transfers: independent dependent

Description with level of assistance needed:
Ambulation: independent assist non-ambulatory
Gait pattern:
Assistive device:
Level of assistance needed:
Stair negotiation:
Child is independent in the developmental sequence to

Self Care (mark the level of assistance needed to complete the task)

undressing dressing eating toileting bathing other

comments:

Assistive technology or adaptive equipment presently used:

The following information was obtained by report observation

Accessibility of the natural environment:

Child’s primary position during play/activities:

Analysis of child’s motor skills while playing:

Analysis of child’s participation in activities:

List of family’s leisure activities:

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Chapter 6 ■ Providing Services in an Early Intervention Program 193

DEVELOPMENTAL SKILLS CHECKLIST

Developmental Checklist:
(Numbers in parentheses indicates the average age in months at which a child typically demonstrates this skill)

Gross Motor
Prone suspension: head at body (2); head above body (3)
Bears weight through legs (4)
Rolling: prone to supine (5); supine to prone (6)
Sitting (6)
Assumes hand and knee (7)
Crawling (8)
Sits on floor for 10 minutes (8)
Pull to Stand (10)
Standing (10)
Walking (12)
Throws ball (13)
Squats (15)
Crawls up steps (15)
Begins to jump (18)
Climbs into adult chair (18)
Carries large toy 2 hands (19)
Walks backwards (24)
Runs (24)
Stairs: step to step (24); alternates up (36)

Fine Motor
Grasp reflex (1)
Hold rattle for 10 sec (2)
Reaches for object (3)
Hands to mouth (4)
Ulnar grasp (4); Palmar grasp (5); Radial grasp (6)
Picks up spoon (5)
Rakes and bangs (6)
Manipulates (7)
Plays with paper (7)
Hold two objects (8)
Developing precision grasps (8)
Hands used for separate functions (9)
Holds, bites and chews cracker (9)
Points (10-11)
Uncovers toy (10)
Holds with one hand and manipulates with another (12)
Unwraps toy (14)
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194 Part II ■ Practice Settings

Holds 3 items (14)

Finer motor development (15-24)
Attemps to fold paper (24)
Turns pages of book separately (24)
Imitates vertical and horiz. line, and circle (27)
Hold crayon with thumb and index (30)
Copies a circle (36)
Cuts across paper with scissors (36)

Cognitive
Watches caregiver (1)
Follows object 180 (2-3)
Smiles (2)
Watches hand (4)
Localizes sound (4)
Laughs (5)
Discriminates strangers (6)
Resists removal of toy (6)
Mouths toy (6)
Bangs and shakes (7)
Understands no (8-10)
Responds to name (9)
Looks when asks “Where is the ball?” (13)
Plays peek a boo (11-14)
Ask for objects by pointing (15)
Looks at pictures and turn pages (18)
Points to one named body part (18); 4 body parts (24)
Follows two directions (18); three directions (21)
Refers to self by name (24)
Understands size difference (27)
Know full name (30)
Knows if they are a boy or girl (36)
Joins in song (36)

Language
Coos (2-3)
Produces single vowel sounds (2)
Squeals (5)
“ba”, “ka”, “na” (8)
Shakes head no (9)
Ma Ma and Da Da (8-10)
2 words (12)
Speaks in 2 word sentences (21)
Asks for food when hungry (21)
Uses pronouns (24)
Uses plurals (3)
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Chapter 6 ■ Providing Services in an Early Intervention Program 195

Self Help

Holds bottle (6)

Holds, bites, and chews (9)
Finger feeds (12)
Takes off hat or shoe (12)
Cooperates with dressing (12)
Pulls off socks (14)
Vocalizes or gestures wants (15)
Imitates housework (16)
Uses spoon (18)
Empties dish when done (18)
Uses toilet (18)
Puts toys away where they belong (21)
Attempts to put shoes on (22); Put on pants (24)
Take off clothes (24); Undresses completely (36)
Spoon feed (24)
Dry hands (30)
Dress with supervision (33)
Unbuttons (36)

Emotional/Social

Crying decreases dramatically (3)

Stranger anxiety (6-8; 15)
Expresses protest (6)
Responds to verbal request (10)
Gives toy to adult upon request (12)
Wants to be near adults (14)
Imitates grown up activities (16)
Parallel play (18); Enjoys roll play (24); Associative play begins (33)

Impairments:
impaired range of motion impaired respiratory function
impaired motor learning impaired muscle strength
impaired balance impaired motor control
impaired coordination impaired mobility
impaired endurance

Functional limitations:
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196 Part II ■ Practice Settings

Other services, equpiment or assistive device recommendations: none

SUMMARY:

Physical Therapist signature Date

Parent’s signature Date