Motor Coordination 11.

Difficulty in copying simple shapes

(circle, square, triangle, rhombus) 12. Difficulty in writing
simple words in language of instruction The child may
have difficulty in forming letters of common words e.g.:
ON, HAT, FUN, BALL, KEY, STOP, etc. Behaviour . 13.
Shows lack of attention and concentration in task. Leaves
work unfinished. The child gets bored easily and leaves
tasks incomplete. The teacher/parent has to constantly ask
the child to pay attention and/or to finish the task. 14.
Restless and/or overactive Has difficulty in sitting in one
position. May roam in the class. May disturb other children
in the class. 15. Tends to be anxious, withdrawn, disruptive
Name:
Signature:
12

1. Reads slowly, and/or guesses words, and/or

uncomfortable reading aloud 2. Skips lines, omits letters
while reading Example: The child may pronounce 'hear as
"her", or omit word(s) from the sentence while reading. 3.
Difficulty in identifying sounds in words For example, the
child is unable to say that /k/ is the first sound in the word
CATCH 4. Difficulty in understanding sentences, passages
Problems in understanding the meaning of written content
related to what has already been taught in the class,
including material in books and on blackboard. Difficulty
in comprehending simple passages (about 6-8 lines) from
story books and text books. WRITING 5. Difficulty in
forming proper letters and words The child writes letters
and/or numbers that are inconsistent or unusual in form and
size. 6. Inaccurate copying from the board and/or book. The
child is unable to copy and/or makes a lot of mistakes in
copying from blackboard and/or textbooks. Unable to use
lines and margins properly. 7. Performs poorly on dictation.
Makes frequent spelling mistakes in common words. 8.
Difficulty in written expression Has difficulties in
expressing ideas on a given topic. Expression is not age
appropriate. MATHEMATICS

9. Poor understanding of basic arithmetic concepts,

symbols such as +, -, x, +, =, etc. The child gets confused
while using these basic signs and/or is unable to understand
the relationship between these arithmetic concepts. 10.
Difficulty in reporting time from wall clocks that are not
digital 11. Slow in mental calculations For example: still
continues to count on fingers, takes significantly longer
time to do simple mental calculations.
COMMUNICATION 12. Difficulty in listening in class
Example: The child may ask teacher to repeat the
instruction, saying, "I did not understand. Can you please
say it again?" 13. Immature speech compared to classmates
Example: "tractor" produced as "taktor". 14. Difficulty in
forming complete sentences orally. Unable to speak in
complete sentences or to produce compound and/or
complex sentences. Example: "I could not do the
homework since I was not well." (complex sentence); "I
read the English chapter but did not complete the math
problem." (compound sentence) Memory 15. Difficulty in
memorizing school content such as multiplication tables,
poems, etc.
Motor Coordination

16. Difficulty in copying or drawing simple shapes

Example: circle, square, triangle, rhombus, pentagon and
hexagon
17. Has an awkward pencil grasp 3ehaviour
18. Shows a lack of attention and concentration on task.
Leaves work unfinished. The child is easily bored in class
and leaves tasks incomplete. The teacher/parent has to
constantly ask the child to pay attention and/or to finish the
task.
19. Restless or overactive Has difficulty sitting in one
position. May disturb other children in the class.
20. Appears to work hard to improve but is unable to
achieve
21. Tends to be anxious/withdrawn/disruptive
Name:
Signature:

[ ] Dramatic change in behavior

[ ] Worries
[ ] Daydream/fantasizes
[ ] Grief
[ ] Fears
[ ] Sadness
[ ] Always tired
[ ] Motivation
[ ] Inattentive
[ ] Withdrawn
[ ] Cries easily for age
[ ] Self image/confidence
[ ] Non-touchable/pulls away
[ ] Nervous/anxious
[ ] Perfectionist
[ ] Aggression/Anger
[ ] Swearing
[ ] Fighting
[ ] Lying
[ ] Bullying
[ ] Disrespectful
[ ] Defiant
[ ] Hurts self
[ ] Impulsive
[ ] Over Active
[ ] Easily distracted

[ ] Academics
[ ] Absences
[ ] Tardy Wk habits/organization
[ ] Completion of Assignments/Homework
[ ] Drop out risk (H.S.)
[ ] Other
[ ] Chews (paper/clothes/hair
[ ] Makes Odd Sounds
[ ] Stealing
[ ] Destruction of Property
[ ] Sexual Acting Out
[ ] Peer Relationships
[ ] Social Skills
[ ] Personal Hygiene
[ ]Family Concerns