Measure of Foundational Abilities - Adolescent
Directions:
Please answer the following questions based on this student's typical behavior during the past month. Use the following rating scale :

Never: the behavior never or almost never happens
Occasionally: the behavior happens some of the time
Frequently: the behavior happens much of the time
Always: the behavior always or almost always happens
Email address *
Name of Adolescent *
Your answer
Name of Parent/Caregiver *
Your answer
Date of Birth of Adolescent *
MM
/
DD
/
YYYY
Balance, Gross & Fine Motor Control
Has trouble distinguishing between left and right *
Shifts preference of dominant hand use for tasks *
Has difficulty learning to type with both hands *
Avoids sports and/or being physically active *
Is constantly moving, tapping foot or pencil, drumming (may increase when trying to pay attention) *
Bumps into people/objects; gets too close to people; unaware of personal space *
Exhibits poor posture, slumps or slouches *
Has poor endurance, is weak and tires easily, avoids physical activity *
Appears clumsy, awkward, or accident prone *
Has poor/illegible handwriting *
Exhibits poor eye hand coordination *
Has difficulty with combining or remembering next movement in a sequence *
Has difficulty learning new motor activities or movements that require more than one step *
Avoids activities that require fine motor manipulation *
Has difficulty catching things *
Demonstrates a poor sense of balance *
Demonstrates poor sense of rhythm, timing *
Has difficulty crossing the midline of the body *
Sensory
Seems bothered by textures on body (i.e. sticky items, clothing fabrics/tags) *
Is bothered by background noise (i.e., humming of lights, ice makers, computers, air conditioners, fans) *
Is bothered by loud and/or unexpected sounds *
Doesn’t like being touched/over responds to unexpected touch/bumps *
Plays too roughly; hurts others inadvertently *
Avoids sustained eye contact *
Is unaware/under-responds to body sensations: hunger, fullness, hot or cold, pain *
Doesn’t seem to notice external sensory stimuli (touch, smells, noise) *
Has difficulty judging force required for task (breaks lead in pencil, holds pencil tightly, throws ball with too much force) *
Has an activity level that seems unusually high *
Has an activity level that seems unusually low *
Seems impulsive/lacks self-control *
Avoids contact with others; avoids crowded places (prefers being by self, standing aside from the group) *
Constantly makes vocal noises, i.e., humming *
Social Emotional
Seems irritable, short-tempered *
Is easily overwhelmed, frustrated by daily activities *
Appears emotionally intense in most activities *
Has frequent mood fluctuations *
Appears anxious, bites nails, face and body are not relaxed *
Is easily upset/hurt; takes a long time to recover *
Does not transition smoothly from one activity to another *
Has difficulty making and keeping friends *
Lacks confidence with new environments and new tasks *
Is not affectionate, not touching or hugging *
Seems “needy”, lacks independence, has low self-reliance, has low self-esteem *
Prefers to interact with others 3 or more years younger *
Responds to situations in an immature manner for age *
Responds with exaggerated emotion to external sensory stimuli *
Avoids social situations; prefers to be alone *
Is possessive with belongings, doesn’t share well *
Lacks tactfulness; acts impulsively *
Seems pessimistic, i.e., expects the worst *
Auditory / Language
Has difficulty following what others are saying *
Says “What?” or “Huh?”, needs instructions repeated, prefers visual cues *
Has difficulty interpreting tone of voice - e.g. angry vs. joking *
Has a delayed response with reacting to speech/directions *
Dislikes shrill sounds, or popping sounds, such as intercom, fire alarms *
Has difficulty determining from what direction a sound is coming *
Confuses similar sounding words, such as 'mouth' and 'mouse' *
Is difficult to understand; doesn’t speak clearly; mumbles *
Speaks with monotone voice *
Has difficulty hearing conversation/instructions in noisy environment *
Is distracted fairly easily by sounds; loses concentration *
Cannot identify words that rhyme *
Needs hands-on or visual instructions along with verbal *
Struggles to express thoughts, ideas *
Has poor reading fluency *
Is unable to complete two unrelated commands (e.g., Complete your essay and place them on my desk.) *
Has difficulty with spelling *
Uses poor grammar; doesn’t speak in complete sentences *
Organization / Attention / Cognitive
Is easily distracted; not able to stay on task *
Needs frequent redirection and/or refocusing toward task at hand *
Forgets/loses items, such as jacket, hat, backpack, homework and other belongings *
Gazes into space/appears to be in own world *
Has difficulty planning ahead (leaving the classroom or gym for another activity) *
Has difficulty self-regulating actions and/or emotions *
Has difficulty sitting still; moves a lot, especially if trying to pay attention *
Interrupts others *
Has disorganized notes or poor study skills *
Has difficulty sitting still during class or for a one-hour instructional period *
Exhibits poor working memory, i.e., forgets things just explained *
Must re-read material several times to comprehend *
Has difficulty listening to plays, poetry or other readings in English class and is unable to maintain attention *
Can’t remember sequential tasks ; e.g. do A, then B, then C *
Omits part of a sequential task, i.e., do A, B, then C *
Is unable to recall the number of letters, numbers, or words in a series equivalent to his/her peers *
Is unable to keep up with new lesson; needs additional time and tutoring *
Has difficulty organizing personal spaces/takes a long time to perform daily activities *
Has difficulty shifting attention from one activity or object to another (more so than peers) *
Is disorganized with school assignments, schedule *
Often fails to begin or complete tasks or projects unless helped *
Starts many tasks or projects, but doesn’t complete them *
Does not recognize cause and effect *
Demonstrates poor judgment and reasoning skills *
Acts before thinking; impulsive *
Constantly makes vocal noises to stay attentive, i.e., humming, talking to self *
Has a tendency to ramble, can't "get to the point" *
Has difficulty organizing thoughts verbally or on paper *
Sleep
Lies awake for half an hour or more before falling asleep *
Awakens more than once during the night *
Cannot get back to sleep easily *
Has fitful sleep cycles (tosses, turns, restless) *
Has thoughts racing through mind preventing getting to sleep *
Awakens during the night with nightmares *
Wakes up grouchy, irritable and mood persists throughout the day *
Feels sleepy and struggles to remain alert during day *
Is hard to wake up in morning *
Has this child experienced any traumatic events, changes in main caregivers, surgeries, abuse or neglect? *
Has this child ever been diagnosed with a developmental issue like but not limited to... PTSD, Autism, ADHD, Processing Issues or Learning Disabilities? *
Is this child currently receiving or received in the past any therapy services? Check all the apply *
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