GROSS MOTOR DOMAIN

PRESEN
GROSS MOTOR MATERIALS/PROCEDURE COMN
T
1. Climbs on chair or Parental report will suffice
other elevated
piece of furniture
like a bed without
help
2. Walks backwards MATERIALS: toy
PROCEDURE:
Ask the child to walk backwards by demonstrating this.
Credit if the child is able to walk backwards without falling and
holding on to anything.

Parental report will suffice.

3. Runs without MATERIAL: ball
tripping or falling PROCEDURE:
Encourage the child to run by rolling a ball across the floor.
Credit if the child can run fast and smoothly without tripping or
falling.
4. Walks downstairs, Automatically credit if item #6 is passed Parental report will
2 feet on each suffice.
step, with one
hand held
5. Walks upstairs MATERIAL: toy
holding handrail, PROCEDURE:
2 feet on each Place a toy in the middle of the 4th or 5th step and ask the child to
step walk up the stairs to get the toy. Credit if the child walks up walks
up the stairs using the handrail or wall for support and places both
feet on each step before stepping on the next one. Automatically
credit if item #6 is passed. Parental report will suffice.
6. Walks upstairs MATERIAL: toy
with alternate feet PROCEDURE:
without holding Place a toy in the middle of the 4th or 5th step and ask the child to
handrail walk upstairs to get the toy. Credit if the child walks upstairs,
alternating his feet as he steps on each successive step without
holding onto the handrail or wall for support. Parenting report
will suffice.
7. Walks downstairs MATERIAL: toy
with alternate feet PROCEDURE:
without holding Place a toy at the bottom of the stairs and ask the child to walk
handrail downstairs to get the toy. Credit if the child walks downstairs,
alternating his feet as he steps on each successive step without
holding on to the handrail or wall for support. Do not give credit
if the child places both feet on the step or uses the handrail or wall
for support. Parental report will suffice.
8. Moves body part PROCEDURE:
as directed Ask the child to raise both arms.
 PRESEN
GROSS MOTOR MATERIALS/PROCEDURE COMN
T
9. Jumps up This must be elicited by the interviewer.
10. Throws ball MATERIAL: ball
overhead with PROCEDURE:
direction Give the child the ball and stand at least 3 feet away from him.
Ask the child to throw the ball to you using an overhand throw.
You may show the child how to do it. Credit if the child throws
the ball within your arm's reach between your knees and head
using an overhand throw and not sideways or underhand
11. Hops 1 to 3 steps PROCEDURE:
on preferred foo Ask the child to lift his foot and hop at least three times on his
preferred foot. Credit if the child is able to hop at least three times
on his preferred foot without holding on to anything.
12. Jumps and turns PROCEDURE:
Ask the child to jump while making a half-turn. Credit if the child
is able to do this without tripping or falling.
13. Dances patterns / Parental report will suffice.
joins group
movement
activities
TOTAL SCORE
FINE MOTOR DOMAIN

FINE MOTOR MATERIALS/PROCEDURE PRESENT COMMEN

1. Uses all 5 fingers to MATERIALS: small toy/ object
get food/toys placed
on flat surface PROCEDURE:
Seat the child on the parent's lap with his elbows at level
with the tabletop and his hands on the table or flat surface.
Drop a small toy in front of him and attract his attention by
pointing to the toy or tapping the table/flat surface. Credit if
the child picks up the toy, using all 5 fingers as if raking.
Automatically credit if he passes the next item.
2. Picks up objects MATERIALS: any small toy
with thumb and or food
index finger PROCEDURE:
Place a toy/food in front of the child and within his reach.
Attract his attention by tapping neat the toy/ food. Credit if
the child uses the tips of his thumb and index or forefinger
to pick up the toy/food.
3. Displays a definite MATERIAL: toy
hand preference PROCEDURE:
Place the toy directly in front of the child at midline (not to
his left or his right) and ask him to reach for this. Credit if
he uses the same hand 2 out of 3 times. Parental report will
suffice.
4. Puts small objects MATERIALS: small objects, container This must be
 FINE MOTOR MATERIALS/PROCEDURE PRESENT COMMEN
in/out of containers elicited by the interviews
5. Holds crayon with MATERIALS: crayon
all the fingers of his PROCEDURE:
hand making a fist
(i.e., palmar grasp) Present child with a crayon and have him get this. Credit if
he holds it by wrapping all 5 fingers around as if making a
fist. Automatically credit this item if he uses the tips of all 5
fingers or his thumb, index and middle fingers. This must be
elicited by the interviews.
6. Unscrews lid of MATERIALS: Container with screw-on top or wrapped
container or candy. This must be elicited by the interviews.
unwraps food
7. Scribbles MATERIALS: paper, pencil/
spontaneously crayon
PROCEDURE:
Place a paper and pencil/ crayon on the table or flat surface
and ask the child to draw anything he wants without
showing him what to do. Credit if the child uses the tips of
his thumb and any of his other fingertips to grasp the
pencil/crayon and makes purposeful marks on the paper (not
accidental marks).
8. Scribbles vertical MATERIALS: paper, pencil/
and horizontal lines crayon
PROCEDURE:
Place a paper and pencil/ crayon on the table or flat surface
and ask the child to draw vertical and horizontal lines after
you have demonstrated these to him. Credit if the child
produces a vertical or horizontal line that is at least 2 inches
long and does not deviate or vary from your vertical line by
more than 30 degrees. The lines may be wavy but not
broken.
9. Draws circle MATERIALS: paper, pencil/
purposely crayon
PROCEDURE:
Place a paper and pencil/ crayon on the table or flat surface
and ask the child to draw a circle or a ball after you have
demonstrate it to him. Credit if the child produces any curve
that is closed or nearly closed. Continuous spiral motions
are not credited.
10. Draws a human MATERIALS: paper, pencil
figure (head, eyes, PROCEDURE:
trunk, arms, hands/ Give the child a pencil and a paper and ask him to draw a
fingers) picture of a person. Credit if the child has draw 3 or more
body parts. A pair is considered one part (eyes, ears, arms,
Draws a house hands, legs, and feet)
using geometric and must be drawn in pairs to get full credit unless the
forms drawing is in profile
MATERIALS: paper, pencil
 FINE MOTOR MATERIALS/PROCEDURE PRESENT COMMEN
PROCEDURE:
Give the child a pencil and paper and ask him to draw a
picture of a house. Credit if the child has drawn at least the
roof, main frame, and a door or window
TOTAL SCORE

SELF-HELP DOMAIN

SELF-HELP MATERIALS/PROCEDURE PRESENT COMMEN

1. Feeds self with finger food (e.g. MATERIALS: bread, biscuits This must be
biscuits, bread) using fingers elicited by the interviewer.
2. Feeds self using fingers to eat Automatically credit if the child eats without
rice/ viands with spillage spillage. Parental report will suffice
3. Feeds self using spoon with Automatically credit if the child eats without
spillage spillage. Parental report will suffice
4. Feeds self using fingers without Parental report will suffice
spillage
5. Feeds self using spoon without Parental report will suffice
spillage
6. Eats without need for spoon Parental report will suffice
feeding during any meal
7. Helps hold cup for drinking MATERIALS: drinking cup, water
Note: The cup should not have a lid or spout.
This must be elicited by the interviewer
8. Drinks from cup with spillage MATERIALS: drinking cup, water

Note: The cup should not have a lid or spout.

This must be elicited by the interviewer.

Automatically credit if he passes the next item.
9. Drinks from cup unassisted MATERIALS: drinking cup, water

This must be elicited by the interviewer.

10. Gets drink for self unassisted Parental report will suffice
11. Pours from pitcher without Parental report will suffice
spillage
12. Prepares own food/ snack Ask the caregiver if the child can prepare his
own snack without help except for getting items
that are hard to reach (e.g. bowl spoon).
13. Prepares meals for younger Parental report will suffice
siblings/ family members
Dressing-sub-domain
14. Participates when being dressed Parental report will suffice
(e.g. raises arms or lifts leg)
15. Pulls down gartered short pants Parental report will suffice
 SELF-HELP MATERIALS/PROCEDURE PRESENT COMMEN
16. Removes sando Parental report will suffice
17. Dresses without assistance Parental report will suffice
except for buttoning and tying
18. Dresses without assistance MATERIAL: small shirt with button and
including buttoning and tying shoestring
PROCEDURE:
Have the child demonstrate how to button in
order to credit this item
Toilet training-sub domain
19. Informs the adult only after he Parental report will suffice
has already urinated (peed) or
moved his bowels (poohed) in
his underpants
20. Informs adult of need to urinate Parental report will suffice
(pee) or move bowels (pooh-
pooh) so he can be brought to a
designated place (e.g. comfort
room)
21. Goes to the designated place to Parental report will suffice
urinate (pee) or move bowels
(pooh) but sometimes still does
this in his underpants
22. Goes to the designated place to Parental report will suffice
urinate (pee) or move bowels
(pooh) and never does this is his
underpants anymore
23. Wipes/Cleans self after a bowel Parental report will suffice
movement (pooh)
Bathing-sub-domain
24. Participates when bathing (e.g. Parental report will suffice
rubbing arms with soap)
25. Washes and dries hands without Ask the caregiver if the child can wash and dry
any help his face without any help or supervision except
to turn on/off faucets that are out of reach.
26. Washes face without any help Ask the caregiver if the child can wash and dry
his face without any help or supervision except
to turn on/off faucets that are out of reach
27. Bathes without any help Parental report will suffice
TOTAL SCORE