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TSBVI OT & PT Screening Forms

The OT Screening Form is a worksheet, not the real report. The report is a narrative that summarizes and interprets the info on the form. The PT form is the actual computerized report that is filled in as a narrative. We write it in language for educators to understand (not medical language). The style ends up being (as one of my interns described it) 'research paper' style. 

We have no 'real' or 'normed' evaluations that we use. So far, we have found the information on normed forms to be not very helpful. Example: A child with a gross motor level of "16 months" really doesn't tell us much about what s/he can do, and whether the low scores are really due to poor motor skills, or to poor cognition and poor desire to move. Many times low scores are due to lack of experience and cognition and motivation , or lack of vision (many motor skills are learned by imitating other kids, so lack of vision means lack of imitation) rather than truly poor motor skills.

The finger isolation and strength for keyboard and braille writer is actually tested on the keyboard and braille writer: Can the student actually make a readable impression on the braille paper? or Press a keyboard hard enough for the computer to process it?

As for the vision issues, we always check on the vision diagnosis and functional vision evaluation. That information really factors in when you have field problems, and primitive motor reflexes interworking. Vision affects head position, body position, and is important to factor into each section of the generic evaluation.

from Brenda Gregory ()

Download OT Screening form in RTF (24.5K)
Download PT evaluation form in RTF (6.5K)

O.T. Screening Form

Student Name:
D.O.B.
Date of Report:
Evaluator

MEDICAL AND SOCIAL HISTORY:

VISUAL FUNCTION:

GROSS MOTOR:

  • Range of Motion
    • active
    • passive
  • Muscle Tone/Quality of Movement
    • flaccid
    • spastic
    • fluctuating
  • Equilibrium Responses/Balance
  • Reflex Behavior

Observe The Following Developmental Skills

  • rolling:
    • segmental
    • log
  • hand/knee crawl
  • commando crawl
  • knee walking

Observe The Following Transitional Movements

  • floor to sit to stand
  • stand to sit to floor

Comments:

FINE MOTOR:

(Determine right or left hand dominance)
use various objects and activities to observe fine motor skills

Prehensile Patterns

  • disc grip (jar lid)
  • spherical (ball)
  • cylindrical
  • standard palmar
  • pinch (2 point tip)
  • tripod (3-jaw chuck)
  • lateral pinch

In-Hand Manipulation Skills

  • shifting
  • translating
  • rotating
  • crumpling

Comments:

Observe Accommodating Responses For Both Hands

Observe Two-Handed Tasks

Describe Eye-Hand Coordination:

SENSORY MOTOR AND SENSORY INTEGRATION SKILLS

Sensory Motor:

  • observe finger isolation skills
  • correct identification of fingers and thumbs for both hands
  • ability to move fingers in isolation from hand motion
  • sufficient finger isolation for Braille writing
  • or using a keyboard
  • communication through gesture
  • or sign language
  • design copy
  • tracing activities

Sensory Integration: use objects and activities to observe sensory

  • responses
  • stereognosis
  • tactile discrimination
  • sensation
  • tactile localization

Describe Proprioceptive Skills

Describe Spatial Awareness Skills

ORAL MOTOR AND FEEDING SKILLS

Oral Motor Skills Check List

  • suck/swallow
  • take food from a spoon
  • bite and chew food
  • bolus formation/movement of food
  • to prepare for swallow

Feeding Skills Check List

  • orient to food
  • ability to grasp and manipulate
  • scoop food
  • utensils
  • napkin
  • hand to mouth pattern
  • drinking cup

Describe Reflex Behavior or Associated Reactions or any unusual

  • movements that occur during eating or toothbrushing

Comments:

Feeding Adaptations Currently Being Used

Suggested Adaptations To Increase Independence For Self-Feeding

Food Texture - suggested food textures to help increase control of jaw, lips, and tongue:

Feeding Position - suggested seating adaptations to improve self-feeding and over-all posture:

posture check list

  • hips, knees, and ankles at 90 degrees
  • head, neck, and back aligned
  • feet flat on the floor
  • adjust table/chair height if needed

FUNCTIONAL LIVING SKILLS

Observe Travel Skills: (independent with cane, sighted guide, hand trailing, familiar and unfamiliar routes, even and uneven surfaces)

Self Care Skills Check List: (is student independent in the following areas, if not describe assistance needed)

  • toileting
  • wash hands with soap
  • wash face
  • brush/comb hair
  • apply toothpaste to toothbrush
  • brush teeth
  • apply deodorant (if applicable)
  • wash upper body
  • wash lower body
  • wash hair
  • dry off with towel
  • doff undergarments
  • don undergarments
  • doff shirt/blouse
  • don shirt/blouse
  • doff pants/shorts
  • don pants/shorts
  • doff dress
  • don dress
  • doff socks
  • don socks
  • doff shoes
  • don shoes
  • zippers
  • snaps
  • unbutton
  • button

List any Adapted Equipment currently used for Toileting, Bathing, Dressing, Classroom Activities, and Computer Accessibility

Suggested Adaptive Equipment to increase independence with Self Care Skills

Comments

COMMUNICATION SKILLS / BEHAVIOR ISSUES

SUMMARY /RECOMMENDATIONS

Physical Therapy Evaluation Form

Name:
DOB: 
Evaluator: 
Title: 
Date of Report: 

Diagnosis:

Reason for TSBVI Referral:

History:

Physical Findings:

Range of Motion:

Posture:

Muscle Tone:

Reflexes:

Strength:

Motor Planning:

Developmental:

Gait/Mobility Skills:

Transitional Skills:

Gravitational Insecurity:

Equipment:

Behavior:

Other Comments:

Problem List:

Strengths:

Weaknesses:

Recommendations:

PT Goals: