ࡱ> 02/ mbjbjWW . 55m || $$C>>S@\cJBi04"/C>>| : Occupational Therapy Referral Checklist Student: ______________________________ Gr: ____ Date: _________________ Date of Birth: ______________ Teacher: _______________OT: ______________ Services student is receiving: ______________________________________________ Please check all areas that apply and return to the occupational therapist at your earliest convenience. Thank you Fine Motor _____ Poor desk posture (slumps, leans on arm, head too close to work, other hand does not assist, sits on leg) _____ Difficulty drawing, coloring copying, cutting, avoidance of these activities _____ Awkward pencil grip _____ Lines drawn are wobbly, written work is too dark,/light; breaks pencil _____ Written work is slow and labored _____ Tires easily when writing _____ Difficulty manipulating scissors _____ Difficulty with buttons, zippers, ties, snaps Visual Motor _____ Difficulty coloring within the lines _____ Difficulty cutting on the line, cuts off corners _____ Unable to copy simple designs (circles, square, triangle) _____ Difficulty staying on the line when writing Visual Perceptual _____ Wears glasses (specify when_________________________) _____ Difficulty naming or matching colors, shapes or sizes _____ Reversals in words, or letters after first grade _____ Difficulty keeping place in reading _____ Difficulty copying from workbook/blackboard Gross Motor _____ Seems weaker or tires more easily than other children his/her age _____ Difficulty with hopping, jumping, skipping, or running compared to others his/her age; does not alternate feet going up stairs _____ Appears stiff and awkward in movements _____ Clumsy or seems not to know how to move body; bumps into things _____ Tendency to confuse right and left body sides Academic/Organizational Behaviors _____ Marked mood variations _____ Becomes easily frustrated _____ Child cannot work independently _____ Difficulty following routine _____ Difficulty interacting with peers _____ Difficulty organizing work space _____ Difficulty problem solving Auditory Language _____ Overly sensitive to noise (please clarify _____________________________) _____ Distracted by background noise _____ Difficulty understanding verbal directions _____ Trouble following 2-3 step commands Movement and Balance/Sensorimotor Behavior _____ Seems to fall frequently _____ Appears to be in constant motion, unable to sit still for an activity _____ Poor balance in motor activities Tactile (Touch) Sensation _____ Appears to be overly sensitive to being touched _____ Has trouble keeping hands to self, will pike or push other children _____ Touches things constantly _____ Avoids putting hands in messy substances (clay, finger paint, paste, sand) _____ Appears to be unaware of being touched or bumped _____ Has trouble remaining in busy or group situation (circle/floor time) Academic Difficulties _____ Reading _____ Math _____ Spelling _____ Slow writer Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ()  i u v | K \ ] i t { " I3HIijklmþþþ÷⾰갬⧰⾢hX@Ch'w?5 h'w?5 hX@C5hmKG hX@ChX@C h/1h/1 h/15h/1h/15h/1 hI&hI&hI&hI&5hI&hX@ChX@C5hX@C hI&5hX@ChI&5CJaJ3()xy  ] x 3 g h i v gdI& 0^`0gdI&gdX@C$0^`0a$gdX@C  J K ] 6 h i u Bo *Jpgd/1 0^`0gd/1gdI&f1}?_23IWcr 0^`0gd/1gd/1jklmdhgdX@C,1h/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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