Form No.

NAME OF CHILD: ____________________________________DATE ADMITTED:____________________

BIRTHDATE: ________________________________________SCHOOL YEAR: ____________________

DIAGNOSIS/ IMPRESSION: ____________________________________________________________________________________

ASSESSMENT FORM FOR CHILDREN WITH DISABILITIES

AREA I: BASIC READINESS: SELF-HELP & INDEPENDENT LIVING SKILLS DEVELOPMENT

Objectives: 1. To develop control of one’s body movement

2. To develop fine motor coordination/control and visual-motor coordination
3. To develop basic skills for independent living

Current/Learning Experiences:

A. G R O S S MOTOR

M D A. 1. Head Balance
________ ________ 1. Raises head in prone, supine and sitting positions
________ ________ 2. Turns head without difficulty

A. 2. Body Turning
________ ________ 1. Supine to side lying
________ ________ 2. Supine to prone
________ ________ 3. Prone to supine
________ ________ 4. Rolls over with ease

A.3. Crawling
________ ________ 1. On stomach: pulls arms/ pushes with legs
________ ________ 2. Four-point: on elbows and knees/ on hands and knees

A.4. Sitting
________ ________ 1. Sits from supine – with or without assistance
________ ________ 2. Maintains balance – lone enough /cross – leg sitting
________ ________ 3. Sits with or without support

A.5. Standing
________ ________ 1. Stands alone or with assistance

A.6. Walking
________ ________ 1. Walks independently (heel to toe gait)
________ ________ 2. Walks with aid: ___________________________
________ ________ 3. Walks with appropriate rhythm
________ ________ 4. Walks backwards/sideways
________ ________ 5. Walks in a straight line / curves with or without object
________ ________ 6. Walks up/down stairs : one foot at a time alternate feet
________ ________ 7. Climbs ladder
________ ________ 8. Steps over obstacles
 A.7. Kneeling
________ ________ 1. Kneels with or without support
________ ________ 2. Unassisted kneel-stand
________ ________ 3. Kneel walks

A.8. Balancing
________ ________ 1. On one foot
________ ________ 2. On tip toes
________ ________ 3. On beam : with or without objects ; following commands
________ ________ 4. Barefoot – picking up with toes
A.9. Running
________ ________ 1. With coordinated movements
________ ________ 2. Runs freely in all directions
________ ________ 3. Runs toward requested direction
________ ________ 4. Sprint

(M –mastered ; D- to be developed)

A.10. Jumping
________ ________ 1. Jumps in place with both feet
________ ________ 2. Jumps from height (_______ inches)
________ ________ 3. Jumps over a stick/string (________ inches) =

A.11. Posture
________ ________ 1. Erect posture while sitting
________ ________ 2. Erect posture while standing
________ ________ 3. Erect posture while walking

A.12. Others
________ ________ 1. Clapping with or without rhythm
________ ________ 2. Ball activities – catch, throw, roll, bounce, kick, shoot, bat
________ ________ 3. Hops
________ ________ 4. Skips
________ ________ 5. Dances
________ ________ 6. Follow calisthenics
________ ________ 7. Pedals/rides a bicycle
________ ________ 8. Uses playground equipment
________ ________ 9. Marches
________ ________ 10. Performs simple or competitive group games

B. F I N E MOTOR preferred hand: _____________________

B.1 Grasping
________ ________ 1. Grasping with one hand
________ ________ 2. Grasps with two hands
________ ________ 3. Transfers objects from one hand to the other

B.2. Various Activities

________ ________ 1. Places objects into and out of container
________ ________ 2. Builds a tower of ______ blocks ; train/bridge of blocks
________ ________ 3. Inserts pegs on pegboard; other objects into slots
________ ________ 4. Strings 5-10 beads
________ ________ 5. Turns the doorknobs, bottle caps, screws belts/nuts (opens-closes)
________ ________ 6. Places match sticks into box
________ ________ 7. Inserts coin/chips into slit
________ ________ 8. Builds with lego, construction toys, blocks
________ ________ 9. Clips/releases clothespins
________ ________ 10. Picks/releases objects with tongs
________ ________ 11. Molds with clay
________ ________ 12. Cuts with scissors – strips / line (straight and curve)
Shapes / around pictures
________ ________ 13. Works on 1 pc. puzzles; / multi-pc. puzzles
________ ________ 14. Pastes shapes within outlines (simple-complicated)
________ ________ 15. Folds paper – simple to complicated / 16 tears paper
________ ________ 16. Opens lock with key
________ ________ 17. Turns pages of a book - ______# of pages
________ ________ 18. Hammers pegs
________ ________ 19. Sews with sewing board
________ ________ 20. Scoops beans

B.3. Pre-writing/Writing
________ ________ 1. Holds crayon/pencil properly
________ ________ 2. Scribbles
________ ________ 3. Shades (a basic shape to simple object) within boundaries
________ ________ 4. Imitates/copies 0, 1 strokes, x, +, , ,
________ ________ 5. Traces, connects from lines = , / , - strokes, x , + , , , , ) , ( ,O
________ ________ 6. Traces, copies number, letters of the alphabet, name (from left to right)
________ ________ 7. Prints numbers, alphabet, name with a model (capital/small letter)
________ ________ 8. Scriptwriting
________ ________ 9.draws objects ; person
________ ________ 10. Copies designs

C. S E L F - H E L P ( Activities of Daily Living-ADL )

C.1. Feeding
________ ________ 1. Drinks from glass/cup/bottle/can
________ ________ 2. Drinks through a straw
________ ________ 3. Eats with fingers when appropriate
________ ________ 4. Eats with spoon and fork
________ ________ 5. Uses knife for spreading/cutting
________ ________ 6. Pours liquid into glass with less or no spillage
________ ________ 7. Scoops food with less spillage
________ ________ 8. Displays good table manners–chews with mouth closed, uses napkin,
does not talk while eating, etc.
________ ________ 9. Cooking

C.2. Toileting
________ ________ 1. Indicates need on time to avoid accidents : gestures/verbal
________ ________ 2. Uses CR independently
________ ________ 3. Completes toileting (flushes, washes, puts-on clothes)
________ ________ 4. Indicates when wet or soiled

C.3. Dressing
________ ________ 1. Takes-off : shirt/blouse, dress, skirt/pants, underwear, shoes/socks
________ ________ 2. Puts-on : shirt/blouse, dress, skirt/pants, underwear, shoes/socks
________ ________ 3. Finds front of clothing
________ ________ 4. Knows how to manipulate a. zipper
b. big/small buttons
c. hook & eye
d. buckle (shoes/belt)
e. snaps
f. lacing shoes
g. tying a bow/ribboning
h. velar

C.4. Hygiene and Grooming

________ ________ 1. Washes hands/face with soap and water
________ ________ 2. Dries face/hands with towel
________ ________ 3. Bathes – with or without help
________ ________ 4. Brushes teeth – places toothpaste, gargles – w/ or w/o assistance
________ ________ 5. Combs hair
________ ________ 6. Keeps nose clean & dry; ears, too (tissue/hanky)
________ ________ 7. Cleans nails

C.5. Care and Grooming

________ ________ 1. Folds clothes, underwear, socks
________ ________ 2. Washes and hangs out hanky/towel
________ ________ 3. Cleans shoes
________ ________ 4. Fixes own things (bag, box, cabinet)
________ ________ 5. Sets table properly
________ ________ 7. Wipes table after eating
________ ________ 8. Washes dishes
________ ________ 9. Sweeps with broom/mops floor
________ ________ 10. Uses dust pan
________ ________ 11. Dusts furniture
________ ________ 12. Cleans mirror
________ ________ 13. Returns chairs, trays & materials, toys after use
________ ________ 14. Rolls and unrolls area rug or mat
________ ________ 15. Throws trash in waste can
________ ________ 16. Garden work – water plants; picks dried leaves
________ ________ 17. Cares for pets

C.6. Travel Skills

________ ________ 1. Knows address
________ ________ 2. Knows phone number
________ ________ 3. Can get a ride – to home/to school
________ ________ 4. Knows traffic signs – traffic signals; when and where to cross the street (pedestrian lane), using
over/underpass; bus/jeepney stop
________ ________ 5. Knows danger signs – e.g. open manholes; deep excavation; train crossing; no pedestrian
allowed; no crossing; no loading & unloading, etc.
AREA II: LANGUAGE, SENSORY & COGNITIVE DEVELOPMENT

Objectives: 1. To provide training for different senses and be aware of oneself

2. To improve communication skills to one’s optimum level through gestures or verbalizations
3. To improve comprehension of spoken or written language
4. To develop understanding of pre-reading concepts
5. To develop recognition/reading of functional words, sentences and comprehend them
6. To improve cognitive process as in reasoning; ability to sort, group/classify; ability to appreciate concepts in everyday
life, etc.
7. To develop mathematical skills
8. To develop other related cognitive skills as in science, social studies, etc.

Content/Learning Experiences:

A. L A N G U A G E

A.1. Receptive Language

________ ________ 1. Responds to auditory stimuli - environmental sounds
________ ________ - familiar voice
________ ________ - familiar objects, music/instruments
________ ________ 2. Responds to verbal stimuli (with or without cues/gestures)
________ ________ - own name
________ ________ - one-step commands (simple)
________ ________ - 2-3 step commands
________ ________ - points to any body part; gives/points familiar objects (concrete pictures)
________ ________ - questions on what, who, when, why, how, where
________ ________ - ordinal, numerical and conditional instructions
________ ________ 3. Listens when spoken to

A.2. Expressive Language

________ ________ 1. Uses non-verbal means of communication
________ ________ 2. Produces unintelligible speech – babbles, coos, jargon, etc.
________ ________ 3. Produces syllables but still meaningless
________ ________ 4.Speaks in one-word sentence
________ ________ 5. Speaks in phrases
________ ________ 6. Speaks in sentences
________ ________ 7. Displays wide vocabulary – objects identification, action, words, etc., adverbs, pronouns, etc.
________ ________ 8. Asks questions appropriately
________ ________ 9. Pitch of voice is appropriate
________ ________ 10. Rate and rhythm is appropriate
________ ________ 11. Intensity of speech is appropriate
________ ________ 12. Articulates well
________ ________ 13. Imitates new words
________ ________ 14. Engages in conversation with one person, peers, class
________ ________ 15. Tells/narrates events, stories, experiences
________ ________ 16. Responds to questions
________ ________ 17. Sings simple songs
B. S E N S O R Y DEVELOPMENT

B.1. Size
________ ________ 1. Discriminates/recognizes differences
________ ________ 2. Identifies/names: big-small / large-tiny
________ ________ tall-short
________ ________ long-short
________ ________ same size
________ ________ 3. Size gradation

B.2. Colors
________ ________ 1. Sorts, matches, groups
________ ________ 2. Names/identifies R B Y G O V BL BR W ; tertiary colors

B.3. Shapes
________ ________ 1. Discriminates, pairs, sorts, groups
________ ________ 2. Names/identifies , , , , , ,

B.4. Tastes
________ ________ 1. Discriminates, matches, pairs
________ ________ 2. Identifies sweet-sour
________ ________ bitter-salty

B.5. Sounds
________ ________ 1. Discriminates, matches, pairs
________ ________ 2. Identifies - environmental sounds
________ ________ - objects
________ ________ - animals
________ ________ - familiar voices
________ ________ - instruments
________ ________ 3. Recognizes sounds which are : high-low
________ ________ - far-near
________ ________ - fast-slow
________ ________ - loud-soft
________ ________ 4. Gradation

B.6. Scents
________ ________ 1. Discriminates, identifies
________ ________ 2. Matches

B.7. Weight
________ ________ 1. Discriminates/identifies light-heavy
________ ________ 2. Weight gradation

B.8. Temperature
________ ________ 1. Discriminates/identifies hot- cold
________ ________ 2. Gradation

B.9. Texture
________ ________ 1. Discriminates/identifies : rough-smooth
________ ________ - soft-hard
________ ________ 2. Gradation
 B.10. Others
________ ________ 1. Object permanence/constancy
________ ________ 2. Visually tracks mazes/pathways, flashlight, etc.
________ ________ 3. Matches picture to actual object
________ ________ 4. Auditory memory : forward/backward
________ ________ 5. Auditory patterning/sequencing
________ ________ 6. Auditory figure-ground discrimination
________ ________ 7. Visual memory
________ ________ 8. Visual patterning/sequencing
________ ________ 9. Visual figure-ground discrimination
________ ________ 10. Visual closure/gestalt completion
________ ________ 11. Stereognosis
________ ________ 12. Spatial relationships/perception of position in space
________ ________ - over-under ________ ________ in-out
________ ________ - front-back ________ ________ on-around
________ ________ - behind-beside-between ________ ________ far-near
________ ________ - up-down/high-low ________ ________ first-last
________ ________ - top-bottom

C. C O G N I T I V E DEVELOPMENT

C.1. Self-Awareness
________ ________ 1. Responds to own name
________ ________ 2. Recognizes boy-girl
________ ________ 3. Identifies self on picture; on mirror
________ ________ 4. Distinguishes “I” – “You”
________ ________ 5. Recognizes own body parts
________ ________ 6. Identifies uses of body parts
________ ________ 7. Identifies own possessions and of others
________ ________ 8. Identifies right and left (laterally/directionality)
________ ________ 9. Recognizes physical characteristics
________ ________ 10. Recognizes own age

C.2. Pre-reading/Reading
________ ________ 1. Identifies more objects, defines terms, recognizes functions/uses; recognizes their parts
________ ________ 2. Describes pictures/situations
________ ________ 3. Groups according to family, uses, gender/genus
________ ________ 4. Pairs, matches alike pictures, symbols (number, alphabet, words, etc.)
________ ________ 5. Notes details – alike-different (similarities-differences)
________ ________ - objects in different direction
________ ________ - missing parts
________ ________ - part-whole relationships
________ ________ - following designs
________ ________ 6. Sees relationships/associations
________ ________ 7. Letter recognition – upper-lower cases
________ ________ 8. Applies phonics – initial sounds
________ ________ - final sounds
________ ________ - middle sounds
________ ________ - CVC blends
________ ________ - long vowel sounds
________ ________ 9. Rhyming words
________ ________ 10. Recognizes opposites (antonym)
________ ________ 11. Recognizes synonyms
________ ________ 12. Reads by phonetics
________ ________ 13. Reads by sight
________ ________ 14. Reads phrases
________ ________ 15. Reads sentences
________ ________ 16. Reads with comprehension
________ ________ 17. Sequences pictures/events/stories (before-after), alphabet, numbers
________ ________ 18. Recalls details from a given situation, retells stories
________ ________ 19. Predicts outcomes
________ ________ 20. Gets main idea of the story
________ ________ 21. Evaluate thinking – makes judgment / conclusion
________ ________ - drawing inferences
________ ________ - absurdities
________ ________ -seeing cause and effect relationships

C.3. Mathematics
________ ________ 1. Knows time vocabulary concepts as in : day-night/morning-afternoon-evening
________ ________ - time to get up, eat (breakfast, lunch, dinner, snack)
________ ________ - time to go to school / to go home
________ ________ - time to play, rest, sleep, etc.
________ ________ 2. Understands quantitative concepts : more-less / many-few
________ ________ - slow-fast / early-late
________ ________ - whole-half
________ ________ - on-off
________ ________ - narrow – wide
________ ________ 3. Rote counts : 0-10 / 11-20
________ ________ 1-50 / 1-100
________ ________ hundreds/thousands
________ ________ 4. Understands number concepts
________ ________ 5. Recognizes number symbols
________ ________ 6. Arranges numbers in sequences : supplies missing numbers
(before, after & between) ; connects /writes, etc.
________ ________ 7. Understands simple / difficult addition
________ ________ 8. Understands simple / difficult subtraction
________ ________ 9. Understands the following symbols : =, ≠ , >, <
________ ________ 10. Applies number words
________ ________ 11. Applies ordinal numbers
________ ________ 12. Understands fractions : ½, ¼, others : _________________
________ ________ 13. Skip counts : 2’s, 5’s, 10’s , others : _________________
________ ________ 14. Recognizes odds and events
________ ________ 15. Applies money concepts (for buying and paying) : ______________________
________ ________ 16. Tells time by hour, 30 minutes, 5’s, by minute, by seconds
________ ________ 17. Reads calendar
________ ________ 18. Knows days of the week/months of the year
________ ________ 19. Knows holidays and special occasions
________ ________ 20. Understands concepts of today, yesterday and tomorrow
________ ________ 21. Comprehends other math activities : measurement & scales _____________
________ ________ - sets ______________________________
________ ________ - multiplication _______________________
________ ________ - division ____________________________
________ ________ - problem solving _____________________
________ ________ - roman numerals _____________________
________ ________ - graphs & maps ______________________

C.4. English Language Arts

________ ________ 1. Naming words, things, people, places (proper and common nouns)
________ ________ 2. Applies plural form of nouns (simple-difficult)
________ ________ 3. Applies pronouns appropriately : he, she, it, I, you, we, they
________ ________ 4. Understands use of possessive pronouns : my, your, his, hers, theirs, ours ; adding ‘s to nouns
________ ________ 5. Comprehends is - are
________ ________ 6. Uses a – an / this – that / these – those
________ ________ 7. Uses has – have correctly
________ ________ 8. Describing words (adjectives)
________ ________ 9. Action words – verbs (present, past, future tenses)
________ ________ 10. Capitalization
________ ________ 11. Punctuation marks: ? ! . ,
________ ________ 12. Kinds of sentences: ? ! . ,
________ ________ 13. Uses what, who, when, where, how, why
________ ________ 14. Adverbs
________ ________ 15. Abbreviations
________ ________ 16. Writing own sentences (sentence completion& construction)
________ ________ 17. Writing a letter
________ ________ 18. Using the telephone
________ ________ 19. Spelling words

C.5. Pilipino
________ ________ 1. Patinig/katinig
________ ________ 2. pagpapantig
________ ________ 3. Pagbasa ng salita, parirala, pangungusap
________ ________ 4. Salitang magkasintunog
________ ________ 5. Pag-unawa sa nabasa
________ ________ 6. Pagsulat ng wastong sagot sa mga tanong
________ ________ 7. Pangngalan- tao, bagay, lugar
________ ________ 8. Pandiwa
________ ________ 9. Pangungusap/pariral:uri
________ ________ 10. Malaking titik
________ ________ 11. Panghalip-uri
________ ________ 12. Pang-uri
________ ________ 13. Gitling, kuwit, tuldok, pananong, etc.
________ ________ 14. Pang-abay
________ ________ 15. Salitang magkasingkahulugan
________ ________ 16. Salitang magkasalungat
________ ________ 17. Paggawa ng liham

C.6. Social Studies (Sibika at Kultura)

________ ________ 1. Family- members: duties of each member
________ ________ 2. Home- parts of the house; materials in building rooms & uses
________ ________ -importance of cleanliness
________ ________ -how to be useful at home; recreation/play
________ ________ 3. Community-neighbourhood: friends, helpers in community & functions
________ ________ -location/interests & equipment
________ ________ 4. Citizenship- own country: national anthem and flag
________ ________ -news/radio/TV for current events
________ ________ 5. Transportation- different modes: importance and how it works
________ ________ -transportation workers

C.7. Science
________ ________ 1. Body parts/functions
________ ________ 2. Classifies sensory experiences
________ ________ 3. Knows food types: sources, importance
________ ________ 4. Plants- importance, types, uses, etc., growth, parts, needs
________ ________ 5. Animals- types, covering, uses, pets, mother-baby, growth, habitat
________ ________ 6. Living and non-living things- characteristics
________ ________ 7. Keeps clean and healthy surroundings, health habits/diseases
________ ________ 8. Matter, energy, motion
________ ________ 9. Earth, space, water forms
________ ________ 10. Weather, seasons
________ ________ 11. Earth, moon, sun, stars

C.8. Music

C.9. Art (creativity/ originality/ own output)

AREA III: AFFECTIVE & SOCIALIZATION DEVELOPMENT

Objectives: 1. To develop an understanding & appreciation of one’s own self & the environment
2. To develop emotional stability
3. To develop effective interaction/ socialization skills with peers and adults
4. To develop considerable range of social graces
5. To foster good study habits/ work attitudes

Content/Learning Experiences

A. A W A R E N E S S of SELF in relation to OTHERS

M D
________ ________ 1. Identifies family members
________ ________ 2. Describes friends & classmates / identifies & addresses correctly
________ ________ 3. Plays with other children * solitary * parallel * associative
*cooperative * competitive * imaginary playmate
________ ________ 4. Participates in group activities – cooperates
________ ________ 5. Understands game rules/plays structured games
________ ________ 6. Wins and loses gracefully
________ ________ 7. Initiates or joins on-going activities
________ ________ 8. Accepted by peers
________ ________ 9. Refrains from destructive behaviour – towards self or others; with self-control
B. R E L A T E D N E S S to OTHERS

________ ________ 1. Reaches for familiar persons

________ ________ 2. Initiates interaction
________ ________ 3. Maintains eye contact
________ ________ 4. Expresses emotion
________ ________ 5. Maintains appropriate social distance
________ ________ 6. Demands personal attention
________ ________ 7. Responds to facial expression
________ ________ 8. Responds positively to praises & compliments
________ ________ 9. Seeks approval for good behaviour
________ ________ 10. Welcomes and entertains visitors
________ ________ 11. Uses “hello-goodbye” appropriately (greetings)
________ ________ 12. Shows affection and assertiveness
________ ________ 13. Follows and leads

C. C O N S I D E R A T I O N for OTHERS

________ ________ 1. Uses polite expressions – thank you, excuse me, sorry, please, etc.
________ ________ 2. Waits for his turn (even in conversations)
________ ________ 3. Shares toys / foods
________ ________ 4. Tolerates delay of gratification of needs / wants
________ ________ 5. Obeys requests / commands cheerfully
________ ________ 6. Offers help
________ ________ 7. Asks permission when borrowing, leaving, going to CR, etc.
________ ________ 8. Accepts mistakes & apologizes (conscience)
________ ________ 9. Accepts suggestions & criticisms in good spirit
________ ________ 10. Respects rights and properties of others and rules
________ ________ 11. Respects authority
________ ________ 12. Offers praises for others

Prepared by: _______________________________________

Date: _____________________

Noted: ____________________________________________