Is my child meeting milestones?
We will use this information to contact you to contact you regarding the results of this OT screener.
What are your areas of concern? (Check all that apply)
Motor Movement (fine-motor/ finger or hand use and manipulation of objects and gross-motor/walking, running, jumping)
Activities of Daily Living (bathing, dressing, eating, feeding, personal hygiene, toileting)
Balance and Coordination (stand on one leg, ride a bike, catch a ball)
Social Participation (making friends, having conversations, reading emotions or gestures of others)
Rest and Sleep (sleep preparation, participation, quality)
Cognitive development (trouble remembering things, paying attention, making decisions, problem solving)
Education and Learning (school, family, community participation)
Sensory Processing (degree in which a child (1. receives, 2. is bothered, 3. interprets, 4. misses) sensation)
Attention (active engagement in activity, shared or paying attention towards others)
Self-regulation (cognitively aware-proper body positioning-emotionally stable)
Speech (sounds of speech, fluency of speech, can you understand the speech)
Language (can the child express themselves, do they understand directions)
What is your most significant area of concern?
Never submit passwords through Google Forms.
This form was created inside of Synergy Healthcare.
Terms of Service