TURNING FIVE OCCUPATIONAL THERAPY PROGRESS REPORT
Date: ____________________
Student’s Name: ______________________ OSIS#: ________________________
Date of Birth: ___________________
Functional Range of Motion: describe areas of limitations and the impact on the child’s ability to perform functional activities i.e. eating, dressing, sitting, play skills.
Fine Motor Skills:
| |Yes |No |Comments |
|Points with index finger | | | |
|Reaches for objects | | | |
|Turns pages | | | |
|Uses crayons, pencil | | | |
|Snips with scissors/thumbs up | | | |
|Cuts along line | | | |
|Cuts out circle | | | |
|Cuts out square | | | |
|Holds/turns paper while cutting | | | |
|Able to copy step pattern using 6 blocks | | | |
|Carries lunchbox | | | |
Describe Grasp:
Pre-Writing:
| |Yes |No |Comments |
|Traces a vertical line | | | |
|Traces a horizontal line | | | |
|Traces a circle | | | |
|Traces a square | | | |
|Imitates a vertical line | | | |
|Imitates a horizontal line | | | |
|Imitates a circle | | | |
|Imitates a square | | | |
|Copies a vertical line | | | |
|Copies a horizontal line | | | |
|Copies a circle | | | |
|Copies a square | | | |
|Draws a vertical line | | | |
|Draws a horizontal line | | | |
|Draws a circle | | | |
|Draws a cross | | | |
|Draws a square | | | |
|Marks, scribbles | | | |
|Connects the dots | | | |
|Colors within the lines | | | |
|Serial opposition –right | | | |
|Serial opposition- left | | | |
|Grasp pattern- circle | | | |
|Power Hook | | | |
| | | | |
|Spherical Cylindrical | | | |
|Skilled use of dominant hand | | | |
|Pinch patterns | | | |
|Lateral Pad to Pat | | | |
| | | | |
|Tip to Tip 3 jaw chuck | | | |
Communication:
| |Yes |No |Comments |
|Verbal | | | |
|Uses gestures | | | |
|Makes eye contact | | | |
|Initiates interaction | | | |
Orientation and Memory:
| |Yes |No |Comments |
|Recognizes self in mirror | | | |
|States name | | | |
|Recognizes body parts | | | |
|Remembers routines | | | |
|Recalls personal events | | | |
|Remembers auditory information | | | |
|Remembers visual information | | | |
Play:
| |Yes |No |Comments |
|Plays alone | | | |
|Plays with others | | | |
|Exhibits imaginary play | | | |
|Exhibits symbolic play | | | |
|Uses toys purposefully | | | |
|Can occupy self | | | |
Life Skills:
| |Yes |No |Comments |
|Puts on jacket | | | |
|Takes off jacket | | | |
|Puts on sweater | | | |
|Takes off sweater | | | |
|Fastens snaps | | | |
|Attempts to zipper | | | |
|Attempts buttons | | | |
|Hangs up coat | | | |
|Drinks from a cup | | | |
|Indicates need to use bathroom in a timely | | | |
|manner | | | |
|Moves from classroom to bathroom and | | | |
|bathroom to classroom | | | |
|Enters and exits stall | | | |
|Locks and unlocks door | | | |
|Manages clothing | | | |
|Obtains toilet paper | | | |
|Uses toilet paper | | | |
|Washes hands | | | |
Self Regulation and Attention:
| |Yes |No |Comments |
|Notices the environment | | | |
|Attends during instruction | | | |
|Follows simple directions | | | |
|Works independently | | | |
|Shifts attention as needed | | | |
|Stays alert | | | |
|Fidgets excessively | | | |
|Waits for turn | | | |
|Follows class rules | | | |
|Adapts to change | | | |
|Transitions easily | | | |
|Responds to familiar people | | | |
|Form attachments | | | |
|Participates in conversation | | | |
|Cooperates in a group | | | |
|Develops friendships | | | |
|Copes with frustration | | | |
Wheelchair Mobility:
Manual or Electric
| |Yes |No |Comments |
|Self propel | | | |
|Able to navigate school | | | |
|Ascend ramp | | | |
|Descend ramp | | | |
|Locks brakes | | | |
|Unlocks brakes | | | |
Sensation:
| |Yes |No |Comments |
|Accepts being touched | | | |
|Assists in personal grooming | | | |
|Touches others appropriately | | | |
|Respects space of others | | | |
|Comfortable using class materials | | | |
|Body awareness | | | |
|Moves without bumping into objects/people | | | |
|Uses a heel-toe gait pattern | | | |
|Imitates a novel movement pattern | | | |
|Incorporates visual, verbal and tactile | | | |
|information | | | |
|Stays alert during class | | | |
|Regulates reaction to stimuli | | | |
|Inhibits excessive movement | | | |
|Attends to instruction | | | |
|Adapts to unpredictable sounds | | | |
|Orients to auditory stimuli | | | |
|Makes eye contact with people | | | |
|Looks at objects | | | |
|Attends to relevant visual info | | | |
|Matches/Sorts colors | | | |
|Matches/Sorts shapes | | | |
|Identifies up, down | | | |
|Identifies under, over | | | |
|Identifies top, bottom | | | |
SUMMARY and RECOMMENDATIONS
| |
|Summary of Present Level of Function (summarize the student’s school-based fine motor function, outlining both strengths and weaknesses and how this may |
|impact their ability to participate in the school environment) |
| |
| |
| |
| |
| |
| |
| |
| |
| |
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|School-Based Occupational Therapy is |
|recommended |
| | Frequency | Duration | Group | |
| | | | | |
| | | | | |
| |
|Explain how School-Based Occupational Therapy will benefit the student’s function and performance in his/her educational program (Please include suggested |
|goals/objectives): |
| |
| |
| |
| |
| |
|not recommended because |
| |
|□ the student’s needs can be met by the primary education program. |
|□ the student’s current function is at an appropriate level given the nature of his/her disability. |
|□ the student’s physical limitations or deficits do not interfere with his/her participation in the school environment. |
|□ the student’s deficits cannot be addressed by school-based occupational therapy. |
|□ others: ___________________________________________________ |
| |
|Other Suggestions |
Therapist’s Name: (Print)___________________ Preschool:___________________
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