Early Identification and Intervention Services Form

Early Identification and Intervention Services

Summary of Assessment

Date of Assessment:

Name of Child:

D.O.B:

Age / Corrected Age:

Gender:

Developmental Age:

Address:

Parents Name:

Email:

Phone No:

Referred by:

Preferred Language:

Primary Concerns

Background Information

General Observation

Child's Initial Reaction:

Appearance and Self-Care

Greeting:

Posture:

Temperament:

Clothing:

Eye Contact:

Behavior

Cooperation with the Therapist:

Attention:

Temperament:

Interest and Motivation:

Play

Exploratory Play:

Relational Play:

Pretending Play:

Constructive Play:

Social Play:

Clinical Evaluation

Observation

History of Neurobehavior:

Sleeping Patterns:

Level of Activity:

Posture:

Movements:

Obvious Deformities:

Attitude of Upper Limbs

Shoulders:

Elbows:

Forearm:

Attitude of Lower Limbs

Right Hip:

Left Hip:

Right Knee:

Left Knee:

Right Ankle:

Left Ankle:

General Appearance

Head:

Face:

Chest:

Abdomen:

Limbs:

Skin:

Motor System

Tone:

Passive Tone:

Adductor Angle:

Dorsiflexion:

Active Tone:

Power:

Nutrition:

Coordination:

Abnormal Involuntary:

Reflexes

Superficial Reflexes

Corneal:

Conjunctiva:

Abdominal:

Deep Tendon Reflexes

Left Biceps:

Right Biceps:

Left Knee:

Right Knee:

Left Ankle:

Right Ankle:

Emerging Reflex

Parachute Reaction to the Lower Limbs:

Parachute Reaction to the Upper Limbs:

Oro Motor Reflex

Sucking:

Swallowing:

Biting:

Spitting:

Sensation

Touch:

Pain:

Temperature:

Higher Function

Examination of Vision

Appearance (Size and Shape):

Nystagmus:

Squint:

Tracking:

Fixation:

Eye-Hand Coordination:

Examination of Hearing

Structure of Ear:

Response to Sound:

High Frequency Sounds:

Low Frequency Sounds:

High Intensity Sounds:

Low Intensity Sounds:

Developmental History

Weight Bearing Positions:

Neck Control:

Rolling:

Sitting:

Crawling:

Standing:

Quadruped:

Keeling:

Half Kneeling:

Squatting:

Single Leg Balance:

Tandem Walking:

Gait:

Functional Reach Test

Functional Reach Test:

Fine Motor Skills

Grasp:

Grip:

Pinch:

Pinch Strength:

Coordination:

Problem Solving:

Motor Planning:

Deformity:

Activities of Daily Living

Brushing:

Bathing:

Toilet Activity:

Buttoning:

Zipping / Unzipping:

Summary

Diagnosis:

Plan:

Early Identification and Intervention Services - Assessment Form