Item

GROSS MOTOR 1 2 19 Informs the adult only after he has already urinated (peed) ✓ ✓ 15 Names 3 animals or vegetables when asked ✓ ✓
No. or moved his bowels (pooped) in his underpants. 16 States what common household items are used for ✓
1 Climbs on chair or elevated piece of furniture like a bed ✓ ✓
20 Informs adult of need to urinate (pee) or move bowels ✓ ✓ 17 Can assemble simple puzzles ✓ ✓
without help (poop) so he can be brought to a designated place (e.g. 18 Demonstrates an understanding of opposites by completing a ✓ ✓
2 Walks backward. ✓ ✓ comfort room) statement (e.g., Ang aso ay malaki, ang daga ay _____”)
3 Runs without tripping or falling. ✓ 21 Goes to the designated place to urinate (pee) or move ✓ 19 Points to left and right sides of body ✓ ✓
4 Walks down stairs, 2 feet on each step, with one hand ✓ ✓ bowels (poop) but sometimes still does this in his 20 Can state what is silly or wrong with pictures (e.g. Ano ang mali sa ✓ ✓
held. underpants. larawang ito?)
5 Walks upstairs holding handrail, 2 feet on each step. ✓ ✓ 22 Goes to the designated place to urinate (pee) or move ✓ ✓ 21 Matches upper and lower case letters ✓ ✓
6 Walks upstairs with alternate feet without holding handrail. ✓ ✓ bowels (poop) and never does this in his underpants TOTAL 20 21
✓ ✓ anymore SCALED SCORE 12 13
7 Walks downstairs with alternate feet without holding
23 Wipes/Cleans self after a bowel movement (poop) ✓ ✓ SOCIO - EMOTIONAL 1 2
handrail.
BATHING SUB- DOMAIN 1 Enjoys watching activities of people or nearby animals. ✓ ✓
8 Moves body part as directed. ✓ ✓
24 Participates when bathing (e.g. rubbing arms with soap) ✓ ✓ 2 ✓ ✓
9 Jumps up ✓ ✓ Friendly w/ strangers but may initially show slight shyness.
25 Washes and dries hands without any help. ✓ ✓
10 Throws ball overhead with direction. ✓ ✓ 3 ✓ ✓
26 Washes face without any help. ✓ ✓ Plays alone but likes to be near to familiar adults or brother and
11 Hops 1 to 3 steps on preferred foot. ✓ ✓ sister.
27 Bathes without any help.
12 Jumps and turns. ✓ ✓ 4 Laughs or squeals aloud in play. ✓ ✓
TOTAL 25 26
13 Dances patterns/joins group movement activities. ✓ ✓ 5 Plays peek-a-boo ✓ ✓
SCALED SCORE 10 12
TOTAL 12 13 6 Rolls ball interactively with caregiver/ examiner. ✓ ✓
RECEPTIVE LANGUAGE 1 2
SCALED SCORE 7 11 ✓ ✓ 7 Hugs or cuddles toys. ✓ ✓
1 Points to family member when asked to do so
8 ✓ ✓
FINE MOTOR DOMAIN 1 2 2 Points to 5 body parts on himself when asked to do so ✓ ✓ Demonstrates respect for elders using “po” and “opo”.
1 Uses all five fingers to get food/toys placed on flat surface. ✓ ✓ 3 Points to 5 named pictured objects when asked to do so ✓ ✓
9 Shares toys with others familiar adults or brother and sister. ✓ ✓
2 Picks up objects with thumb and index finger. ✓ ✓ 4 Follows one-step instructions that include simple ✓ ✓
10 Imitates adults activities (e.g. cooking, washing) ✓ ✓
3 Displays a definite hand preference. ✓ ✓ prepositions (e.g., in, on, under, etc.)
11 Identifies feelings of others. ✓ ✓
4 Puts small objects in/out of containers. ✓ ✓ 5 Follows 2-step instructions that include simple ✓
12 Appropriately uses cultural gestures of greetings without much ✓ ✓
5 Holds crayon with all fingers of his hand making a fist (i.e. ✓ ✓ prepositions
prompting( e.g. mano/bless, kiss, etc.)
palmar grasp) TOTAL 4 5
13 Comforts playmates/siblings in distress. ✓ ✓
✓ SCALED SCORE 8 11
6 Unscrews lid of container or unwraps food. 14 Persists when faced with a problem or obstacle to his wants. ✓ ✓
✓ ✓
EXPRESSIVE LANGUAGE 1 2
7 Scribbles spontaneously. 15 ✓ ✓
1 Uses 5-20 recognizable words ✓ ✓ Helps with family chores(e.g. wiping tables, watering plants)
8 Scribbles vertical and horizontal lines. ✓ ✓
2 Uses pronouns (e.g. I, me, ako, akin) ✓ ✓
9 Draws circle purposely. ✓ ✓ 16 Curious about environment but knows when to stop asking questions ✓ ✓
3 Uses 2-3 words verb-noun combinations (e.g. hingi gatas) ✓ ✓
10 Draws a human figure (head, eyes, trunk, arms, ✓ ✓ to adult.
4 Names objects in pictures ✓ ✓
hands/fingers) 17 ✓ ✓
5 Speaks in grammatically correct 2-3 word sentences ✓ ✓ Waits for turns.
11 Draws a house using geometric forms. ✓ ✓ ✓ ✓
6 Asks “what” questions 18 ✓ ✓
TOTAL 10 11 7 Asks “who”' and “why” questions ✓ ✓ Asks permission to play with toys being used by others.
SCALED SCORE 10 12 8 Gives account of recent experiences (with prompting) in ✓
19 ✓ ✓
SELF - HELP DOMAIN 1 2 order of occurrence using past tense Defends possessions with determination.
1 Feeds self with finger foods (e.g. biscuits, bread) using ✓ ✓ TOTAL 7 8 20 Plays organized group games fairly(e.g. does not cheat in order to ✓ ✓
fingers SCALED SCORE 5 11 win).
2 Feeds self using fingers with spillage ✓ ✓ COGNITIVE DOMAIN 1 2 21 Can talk about difficult feelings (e.g. anger, sadness, worry) he ✓ ✓
3 Feeds self using spoon with spillage ✓ ✓ 1 Looks at direction of fallen object ✓ ✓ experience.
4 Feeds self using fingers without spillage ✓ ✓ 2 Looks for partially hidden object ✓ ✓ 22 Honors a simple bargain with caregiver (e.g., can play outside only ✓ ✓
✓ ✓ 3 Imitates behavior just seen a few minutes earlier ✓ ✓ after cleaning/fixing his room)
5 Feeds self using spoon without spillage
✓ ✓ 4 Offers object but will not release it ✓ ✓ 23 ✓ ✓
6 Eats without need for spoon feeding during any meal Watches responsibly over younger siblings/family members.
5 Looks for completely hidden object ✓ ✓
7 Helps hold cup for drinking ✓ ✓
6 Exhibits simple pretend play (feed, put doll to sleep) ✓ ✓ 24 Cooperates with adults and peers in group situations to minimize
8 Drinks from cup with spillage ✓ ✓
7 Matches objects ✓ ✓ quarrels and conflicts.
9 Drinks from cup unassisted ✓ ✓
8 Matches 2 – 3 colors ✓ ✓ TOTAL 23 23
10 Gets drink for self unassisted ✓ ✓
9 Matches pictures ✓ ✓ SCALED SCORE 11 11
11 Pours from pitcher without spillage ✓ ✓
10 Sorts objects based on 2 attributes (e.g., size and color) ✓ ✓ SUM OF SCALED SCORE 63 81
12 Prepares own food/snacks ✓ ✓
11 Sorts objects based on 2 attributes (e.g.,shape and color) ✓ ✓ STANDARD SCORE 86 113
13 Prepares meals for younger siblings/ family members ✓ ✓ ✓ ✓
12 Arranges objects according to size from smallest to INTERPRETATION:
when no adult is around biggest
DRESSING SUB-DOMAIN 13 Names 4 – 6 colors ✓ ✓
1.____Average overall development_____________________________
14 Participates when being dressed ✓ ✓ 14 Copies shapes ✓ ✓
15 Pulls down gartered short pants ✓ ✓
✓ ✓
District: ____Rosario West_________ 2.____Average overall development_____________________________
16 Removes sando
17 Dresses without assistance except buttons and tying ✓ ✓
18 Dresses without assistance including buttons and tying ✓ ✓

School: ____Antipolo Elementary School_______

 September

November

December

February
October

January

TOTAL
March

June
April

May
School
16 26 23 15 24 21 27 22 14 21 209
Days
Days
16 26 23 15 24 21 27 22 14 21 209
Present
Days
0 0 0 0 0 0 0 0 0 0 0
✓ Absent

Examiner’s Tardy 0 0 0 0 0 0 0 0 0 0 0
Year Month Date
Name
Date Tested 2021 09 24 Jingky P. Rayos
1st Child’s Date
of Birth
2015 12 29
Assess
Parent/Guardian’s Signature
✓ Child’s Age 5 8 25
Date Tested 2022 05 16 Jingky P. Rayos
nd
2 Child’s Date
of Birth
2015 12 29 1st Quarter
Assess
Child’s Age 6 4 17
2nd Quarter

1st Assessment 2nd Assessment

DOMAIN Raw Scaled Raw Scaled
Score Score Score Score
Gross Motor 12 7 13 11
Fine Motor 10 10 11 12
Self-Help 25 10 26 12
Receptive Language 4 8 5 11
Expressive Language 7 5 8 11
Cognitive 20 12 21 13
Socio-Emotional 23 11 23 11
Sum of Scaled 63 81
Scores
Standard Score 86 113
Interpretation Average overall Average overall
development development

Attendance Record