Occupational Therapy Form Clinic Location Child has appointment scheduled at* Pooler Richmond Hill Name* Date of Birth* Month Day Year Today's Date* Month Day Year If your child is being evaluated for OT (occupational therapy)… Please check any of the following performance skill areas that your child is having difficulty with.VISUAL PERCEPTION Inattention and distractibility to written and/or reading tasks Difficulty in letter recognition and letter reproduction Reversal of letters such as b for d or p for q Difficulty copying from a blackboard or whiteboard Poor orientation of puzzle pieces – gives up Poor at following instructions SELF CARE Dressing: clothes or shoes on backwards Dressing: shoes on wrong feet Food pushed off plate Messy eater Picky eater Choke on food/liquids Finger feeding independently Use a spoon/fork independently Chew solid foods Show aversion to water (such as bathing, face washing, etc) Brush teeth or allow teeth to be brushed SOCIAL SKILLS Withdrawal from social situations Lack of group interaction (avoidance) Lack of confidence in oneself Making friends/getting along with others Poor eye contact Poor body language FINE MOTOR No interest in fine motor skills Awkward pencil grasp Poor scissor skills Clumsy grasp & release skills Difficulty holding small objects, manipulating tools, pencils, or scissors Unable to complete mazes, dot-to-dots, etc. Difficulty copying text from whiteboard or blackboard GROSS MOTOR (MOTOR AND PRAXIS SKILLS) Flinching and other responses when catching a ball Fear response to gross motor activities Unable to hop, skip, jump, run, etc. Maintaining balance while walking on an uneven surface Difficulty coordinating body sides EMOTIONAL REGULATION Responding to the feelings of others by acknowledgement or showing support Controlling anger toward others and reducing aggressive acts Recovering from a hurt or disappointment without lashing out at others Displaying emotions that are appropriate for the situation Persisting in task despite frustrations Utilizing relaxation strategies to cope with stressful events SENSORY PROCESSING & REGULATION Difficulty calming down Over-responsive to sensation, Fight or Flight response to sensation (aka sensory defensiveness) Under-responsive to sensation, seem to have an insatiable desire for sensory stimulation Motor problem skills – problems planning and carrying out new actions, difficulty forming a goal or idea or developing new motor skills Δ