Free Occupational Therapy Pediatric Evaluation Template
Occupational Therapy Pediatric Evaluation
Date: [Insert Date]
Introduction
This form facilitates a comprehensive Occupational Therapy Pediatric Evaluation, focusing on a child's developmental, motor, sensory, and functional abilities.
Overview
This assessment guides intervention planning and functional goal-setting, thereby enhancing participation in daily activities for optimal growth and development.
Evaluation Criteria
The criteria for this assessment include Developmental Milestones, Motor Skills, Sensory Processing, and Functional Skills. Further descriptions are given in the evaluation section.
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Patient Information |
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Name: |
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Age: |
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Date of Birth: |
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Medical History |
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Developmental milestones: |
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Diagnoses: |
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Medications: |
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Allergies: |
Evaluation
Instructions: Rate the child's sensory processing abilities on a scale of 1 to 5, with 1 indicating significant challenges and 5 indicating strong sensory processing skills.
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Criteria |
Description |
Rating (1-5) |
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Developmental Milestones |
Assess the child's progress in reaching developmental milestones in areas such as speech, social skills, and cognitive development. |
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Motor Skills |
Evaluate the child's gross (e.g., running, jumping) and fine motor skills (e.g., writing, buttoning). |
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Sensory Processing |
Assess the child's ability to process and respond to different sensory stimuli, including tactile, auditory, and visual stimuli. |
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Functional Skills |
Evaluate the child's ability to perform necessary daily tasks such as dressing, eating, and toileting. |
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Social Skills |
Assess the child's ability to interact with peers and adults, including communication, sharing, and turn-taking. |
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Emotional Regulation |
Evaluate the child's ability to manage and express emotions appropriately in various situations. |
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Attention and Concentration |
Assess the child's ability to sustain attention and focus on tasks for an appropriate amount of time. |
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Play Skills |
Evaluate the child's ability to engage in age-appropriate play activities and use imagination creatively. |
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Cognitive Skills |
Assess the child's problem-solving abilities, memory, and understanding of concepts such as numbers, shapes, and colors. |
Additional Notes
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Additional Comments & Notes |
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Confidentiality Note: All information collected during this evaluation is confidential and will be securely stored in compliance with privacy regulations. Access to this information is restricted to authorized personnel only, ensuring the privacy and security of the patient's personal and medical data.
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