General Instructions: This questionnaire is composed of six parts.

Please
read all questions carefully and shade the corresponding box for your
answer.

1 – Strongly Agree
2 – Agree
3 – Neither Agree nor Disagree
4 – Disagree
5 – Strongly Disagree

BALANCING ACTIVITIES

Please read carefully: Please shade your answer:

1. The child can walk straight forward. 1 2 3 4 5
2. The child can walk straight 1 2 3 4 5
backwards.
3. The child can walk in heel-toe 1 2 3 4 5
straightly forward.
4. The child can walk in heel-toe 1 2 3 4 5
straightly backwards.
5. The child can walk in tiptoe straightly 1 2 3 4 5
forward.
6. The child can walk in tiptoe straightly 1 2 3 4 5
backward.
7. The child can stand still. 1 2 3 4 5
8. The child can stand on one foot. 1 2 3 4 5
9. The child can stand on a chair 1 2 3 4 5
without falling.
10. The child can walk forward with 1 2 3 4 5
eyes closed.
11. The child can kick a ball without 1 2 3 4 5
falling.
12. The child can balance a small- 1 2 3 4 5
sized object on his head.
Ref: Fundamental Movement Skills Teacher Resource (2004), Book 2, p.128, W. Australia
Minister for Education

JUMPING/HOPPING ACTIVITIES

Please read carefully: Please shade your answer:

1. The child likes to jump around. 1 2 3 4 5
2. The child likes to dance. 1 2 3 4 5
3. The child can gallop like a horse. 1 2 3 4 5
4. The child can hop like a bunny. 1 2 3 4 5
5. The child can leap over obstacles. 1 2 3 4 5
6. The child can jump to reach objects. 1 2 3 4 5
7. The child can jump from a higher 1 2 3 4 5
position to a lower position.
8. The child can jump from a lower 1 2 3 4 5
position to a higher position.
9. The child can perform jumping jacks. 1 2 3 4 5
10. The child can hop using one foot. 1 2 3 4 5
11. The child can hop while exchanging 1 2 3 4 5
one foot to another.
12. The child can jump as far as 0.5 1 2 3 4 5
meter.
Ref: Anderson, L. (2009). A Hop, Skip and a Jump: Enhancing Physical Literacy. Mount Royal
College.

EYE/HAND COORDINATION

1. The child can throw/fling an object 1 2 3 4 5

away from him/her.
2. The child can catch an object thrown 1 2 3 4 5
to him/her.
3. The child can grasp objects tightly. 1 2 3 4 5
4. The child can stock blocks or other 1 2 3 4 5
objects.
5. The child can draw horizontal and 1 2 3 4 5
vertical lines using a pen, crayon or
pencil.
6. The child can scribble using a pen, 1 2 3 4 5
crayon or pencil.
7. The child can complete a familiar 1 2 3 4 5
puzzle.
9.The child can tie his/her own 1 2 3 4 5
shoelaces.
10. The child can catch floating/flying 1 2 3 4 5
objects.
11.The child marks the word/pictures 1 2 3 4 5
using fingers when reading.
12. The child can unwrap gifts or rip 1 2 3 4 5
papers.
Ref: Hand-Eye Coordination: Toddlerhood, Preschool Years, School-aged
Children. (2015). Net Industries
CORE STRENGTH

Please read carefully: Please shade your answer:

1. The child can stand straight. 1 2 3 4 5
2. The child can sit-up straight. 1 2 3 4 5
3. The child can kneel. 1 2 3 4 5
4. The child can kneel with one leg and 1 2 3 4 5
with other foot forward (half-kneeling).
5. The child can lift his/her own arms. 1 2 3 4 5
6. The child can lift his/her own legs. 1 2 3 4 5
7. The child can lift heavy objects. 1 2 3 4 5
8. The child can lift himself/herself 1 2 3 4 5
when fallen.
9. The child can stand on hands and 1 2 3 4 5
knees like a dog.
10. The child can hang himself/herself 1 2 3 4 5
in to a stable branch/object using
his/her hands/legs.
11. The child can climb a ladder. 1 2 3 4 5
12. The child can swing himself/herself 1 2 3 4 5
in the playground swing.
Ref: Learn to Move, Move to Learn. (N.D.). Physiotherapy Services, Department
of Education and Training, Queensland Government

GENERAL STRENGTH

Please read carefully: Please shade your answer:

1. The child can go up the stairs. 1 2 3 4 5
2. The child can go down the stairs. 1 2 3 4 5
3. The child can pull a chair. 1 2 3 4 5
4. The child can push a chair. 1 2 3 4 5
5. The child can swim. (Even with 1 2 3 4 5
floaters)
6. The child can kick a ball. 1 2 3 4 5
7. The child can crawl. 1 2 3 4 5
9. The child can bounce in bed. 1 2 3 4 5
10. The child can run fast. 1 2 3 4 5
11. The child can jog but stays in place. 1 2 3 4 5
12. The child is active in playing 1 2 3 4 5
outdoors.
Ref: Learn to Move, Move to Learn. (N.D.). Physiotherapy Services, Department
of Education and Training, Queensland Government