A. BASIC DETAILS
1. Name
2. Address
3. Date of birth
4. Date of assessment
5. Age at assessment
6. School name
7. Date of report
8. Prepared by
9. Parents name
10. Contact details
B. Reason for Referral:
C. Background Information:
1. Family information:
2. Birth & Medical History
3. Details about milestones
4. Hearing and vision
D. Assessment Report:
1. General Observation:
2. Muscle tone
3. Range of motion
a. Knee flexed
b. Knee extended
c. Hip rotation
d. Other observation
4. Control:
a. Shoulder control
b. Pelvic control
c. Active trunk extension
d. Active trunk flexion
5. Coordination:
a. Eye hand coordination
b. Eye foot coordination
6.
Spatial awareness
7. Midline crossing
8. Directionality
9. Symmetry in ovements
10. Opposite patterns
11. Balance
a. Sitting
b. Standing
c. Other observations
12. Gross motor
a. Supine activities
b. Sitting
c. Kneeling
d. Standing
e. Gait
f.
Running
g. Stairs
h. Hopping/jumping
13. Behavior during observation
14. Challenging areas
15. Suggestion from physiotherapist
Signature/name of physiotherapist
Date