Assessment

Checklist on
Different Child’s
Difficulty
 Assessment Checklist on Difficulty in Seeing

Totally Blind
Characteristics Yes/No Remarks Intervention
1. Lack of usable vision.

2. Receive no stimuli from their

visual channel.

3. Depend entirely on input from

other senses such as touch,
hearing, smelling, and tasting.

4. The sense of touch is very keen.

5. Move slowly and carefully due

to the fear of bumping into
things or objects.

6. Move, feel, and touch objects,

especially when traveling, to
ensure they are on the right
path.

7. Lack of light perception.

8. Use tactile and auditory

channels for learning and
functional tasks.

9. Use cane for mobility.

10.Learn via Braille and other

non-visual media.
 Low Vision/Partially-sighted
Characteristics Yes/No Remarks Intervention
1. Have vision between 20/70-
20/160 and cannot be
corrected.

2. Use correctional glasses and

3. contact lenses.

4. Uses tactile and auditory

channels for learning.

Screened by:
___________________________
Signature over printed name

Date: _____________
 Assessment Checklist on Difficulty in
Basic Learning and Applying Knowledge
Characteristics Yes/No Remarks Intervention
1. Difficulty learning connections
between letters and sounds

2. Confused in short words (at

and to)

3. Letter reversals

4. Word reversals

5. Frequently adds and/or forgets

letters in a word

6. Difficulty in remembering
simple sequences

7. Difficulty keeping in place when

reading

8. Poor sequencing of numbers

9. Poor spelling

10.Avoids reading aloud

11.Difficulty organizing ideas to

speak or write

12.Avoids writing tasks

13.Left and Right confusion

14.Slow to memorize tasks and

math

15.Trouble following oral

instructions

16.Appearing restless or easily

distracted

17.Difficulty in reading
18.Difficulty in writing

19.Difficulty in spelling

20.Difficulty in counting and

calculating

Screened by: Date:

___________________________ _______________________
Signature over printed name
 Assessment Checklist on Difficulty in
Remembering and Concentrating

Physical and Motor Characteristics

Characteristics Yes/No Remarks Intervention
1. Is slightly lighter in weight than
most children of his/her own
group

2. Is shorter in height than most

children of his/her own age
group

3. Walks with stooping shoulders

4. Walks with uncoordinated

swaying of the arms

5. Tendency to trip or stumble over

objects while walking

6. Tendency to drop objects and

articles

7. Has difficulty in maintaining

balance while jumping, hopping,
and skipping

8. Has difficulty in using scissors

9. Has difficulty in using knives for

slicing, paring, and cutting

10.Finds difficulty in tying

shoelaces, ribbons or sash

11.Is unable to hold pen or pencil

correctly

12.Has difficulty in tracing circle,

square and triangle

13.Has difficulty in drawing a circle

14.Has difficulty in drawing triangle

15.Has difficulty in drawing square

16.Has difficulty in writing letters of

the alphabet

17.Finds difficulty in writing

numbers

18.Has the following physical

deformities
 Dry, course and scaly
skin
● Slanted eyes with
coordinated eye muscles
● Protruding forehead
● Large protruding tongue
● Wide face
● Disproportionately short
hands and fingers
● Broad hands with fingers
having square ends
● Teeth that are peg shaped
and chalky
● Swollen eyelids and eyes
that are half-shut
● Short thick neck
● Short thick legs
● Large head
● Disproportionately small
head

Personal and Social Characteristics

 Characteristics Yes/No Remarks Intervention
1. Tendency to be alone most of
the time

2. Easily cries

3. Tendency to get angry at a

slight provocation

4. Lacks concern and attention to

events and people around him

5. Talks and laughs in an

unnecessarily loud voice

6. Tendency to over react to

events and people around him

7. Does not care about the

feelings of others

8. Does not laugh easily when

confronted with funny
situations

Learning Characteristics
Characteristics Yes/No Remarks Intervention
1. Has short attention span

2. Has poor memory

3. Has difficulty in comprehending

situations in communication

4. Is easily distracted around

him/her

5. Has difficulty in finishing work

that has been started

6. Perseverates or repeats
unnecessary action

7. Has reversals in written work

8. Has difficulty in relating
isolated facts into meaningful
ideas

Spoken Language
Characteristics Yes/No Remarks Intervention
1. Refuses to talk

2. Has the tendency to speak in

words or phrases instead

3. Tendency to talk in sentences

with grammatical errors

4. Has immature or improper

vocabulary

5. Tendency to have articulation

problems such as:

a. omissions

b. substitutions

c. additions

d. additions

6. Gropes for words to express

himself

Screened by:
___________________________
Signature over printed name

Date: ________________________________

Assessment Checklist on Difficulty in Performing

Adaptive Skills
 Characteristics Yes/No Remarks Intervention
1. Difficulty in dealing with other
children

2. Acts as deaf

3. Resists learning

4. No fear of real dangers

5. Resists change in routine

6. Indicates need by gesture

7. Inappropriate laughing and

giggling

8. Not cuddly

9. Marked physical over activity

10.No eye contact

11.Inappropriate attachments to
objects

12.Spins objects

13.Sustained odd play

14.Standoffish manner

15.High pain tolerance

Characteristics on Conceptual Skills

Characteristics Yes/No Remarks Intervention
1. Seems forgetful, easily
 distracted or daydreaming

2. Appears not to listen and has

trouble following directions

3. Interrupts people, blurts things

out inappropriately and may
struggle with nonverbal cues

4. Acts without thinking and may

not understand the
consequences of his actions

5. Has obsessive interests and

experiences perseveration

6. Disobey rules and policies

7. Fails to finish school works

8. Does not seem to listen when

spoken to

9. Fall asleep easily in class

Characteristics on Social Skills

Characteristics Yes/No Remarks Intervention
1. Struggles with organization and
completing tasks

2. May overreact to sensory input,

like the way things sound,
smell, taste, look or feel

3. Gets upset by changes in

routine

4. Reacts strongly to the way

things sound, smell, taste, look
or feel (sensory processing
issues)

5. Difficulty working
independently in daily chores
6. Uses eating utensils
inappropriately

7. Unable to put on shoes by

himself

8. Unable to fold clothes

9. Difficulty in preparing simple

meals

Screened by:
___________________________
Signature over printed name

Date: ________________________________

Assessment Checklist on Difficulty in Displaying

Interpersonal Behavior

Characteristics Yes/No Remarks Intervention

1. Bullies and threatens
classmates and others

2. Initiates physical fights

3. Has little empathy for others

and has lack of appropriate
feelings of guilt

4. Lies to peers or teachers

5. Steals from peers or the school

6. Shows fearfulness and

apprehension

7. Has difficulty in
mingling/interacting with
others

8. Has low self-esteem masked by

showing boldness intended to
impress or intimidate

9. Afraid of consequences of
activities

10.Constantly seeks affirmation

from others

11.Deliberately annoys others

12.Worries about things that

might happen or have
happened

13.Criticizes self and others

14.Avoids things or places or

refuses to do things or go
places

15.Expresses feelings of
worthlessness, hopelessness
16.Blames self and others for one’s
mistakes or misbehavior

17.Has lack of interest in

classroom/school activities

18.Thinks or talks repeatedly of

suicide

19.Afraid of failure, rejection and

embarrassment

20.Avoids work activities that

involve contact with others

21.Avoids work activities that

involve contact with others

22.Has the tendency to use and

abuse prohibited drugs and
alcohol

23.Defies and refuses to comply

with rules and teacher's
requests

Screened by:
___________________________
Signature over printed name

Date: ________________________________

Difficulty in Speech and Language

 Characteristics Yes/No Remarks Intervention
Usually has no speech

If he has spoken, he…

● Uses limited vocabulary

● Speaks in words instead of
sentences
● Is particularly poor in
spelling
● Is poor in dictation
● Talks with poor rhythm

Screened by:
___________________________
Signature over printed name

Date: ________________________________