Signs & Symptoms Signs & Symptoms This field is hidden when viewing the formUUIDThis field is hidden when viewing the formDoc IDClient Name First Last Date MM slash DD slash YYYY This field is hidden when viewing the formEvaluationInitial1st Progress Check2nd Progress Check3rd Progress CheckThis field is hidden when viewing the formSections Pre-Kindergarten School-Age Balance & Coordination Visual Perception Eye Teaming Sensory Emotion/Behavioral Attention Visual Auditory Social Speech/Communication Oral Issues Gross Motor Fine Motor Other Goals Select AllPre-Kindergarten AgePlease assess your child’s signs and/or symptoms in the following areasDifficulty with letter formation Not Present Mild Somewhat Severe Severe Does not like to color or draw Not Present Mild Somewhat Severe Severe Struggles with scissors skills Not Present Mild Somewhat Severe Severe No established left or right hand dominance by age 5 Not Present Mild Somewhat Severe Severe School-AgePlease assess your child’s signs and/or symptoms in the following areasMessy Handwriting Not Present Mild Somewhat Severe Severe Writes letters using own approach and pattern Not Present Mild Somewhat Severe Severe Challenges with letter formation Not Present Mild Somewhat Severe Severe Challenges with size of letters Not Present Mild Somewhat Severe Severe Challenges with spacing within a word and between words Not Present Mild Somewhat Severe Severe Improper use of margins Not Present Mild Somewhat Severe Severe Writes uphill, downhill or at angles across page Not Present Mild Somewhat Severe Severe Mixes uppercase and lowercase letters Not Present Mild Somewhat Severe Severe Frequent letter and/or number reversals Not Present Mild Somewhat Severe Severe Does not like to write Not Present Mild Somewhat Severe Severe Rushes to get handwriting work done Not Present Mild Somewhat Severe Severe Does not take time to erase mistakes Not Present Mild Somewhat Severe Severe Has to redo written work often Not Present Mild Somewhat Severe Severe Writes short answers when you know they have more to say Not Present Mild Somewhat Severe Severe Homework takes a long time Not Present Mild Somewhat Severe Severe Holds pencil incorrectly Not Present Mild Somewhat Severe Severe Complains of hand being tired or hand hurting when writing Not Present Mild Somewhat Severe Severe Grades are suffering due to handwriting Not Present Mild Somewhat Severe Severe Balance And CoordinationPlease assess your child’s signs and/or symptoms in the following areasDelays in sitting up, rolling over or walking Not Present Mild Somewhat Severe Severe Sitting Up Not Present Mild Somewhat Severe Severe Rolling over Not Present Mild Somewhat Severe Severe Walking Not Present Mild Somewhat Severe Severe Difficulty learning how to handle utensils: fork, knife, spoon Not Present Mild Somewhat Severe Severe Poor ball skills such as kicking, catching or throwing Not Present Mild Somewhat Severe Severe Kicking Not Present Mild Somewhat Severe Severe Catching Not Present Mild Somewhat Severe Severe Throwing Not Present Mild Somewhat Severe Severe Issues riding bike, galloping, hopping, or skipping Not Present Mild Somewhat Severe Severe Riding Bike Not Present Mild Somewhat Severe Severe Galloping Not Present Mild Somewhat Severe Severe Hopping Not Present Mild Somewhat Severe Severe Skipping Not Present Mild Somewhat Severe Severe Issues with tying shoelaces, fastening buttons or getting dressed Not Present Mild Somewhat Severe Severe Shoelaces Not Present Mild Somewhat Severe Severe Fastening Buttons Not Present Mild Somewhat Severe Severe Getting Dressed Not Present Mild Somewhat Severe Severe Clumsiness/bumps into objects and people Not Present Mild Somewhat Severe Severe Delay in crawling or abnormal crawling (such as bear walk instead of crawl) Not Present Mild Somewhat Severe Severe Poor eye-hand coordination Not Present Mild Somewhat Severe Severe Balance or stability problems (especially when looking up or down) Not Present Mild Somewhat Severe Severe Motor coordination disorders Not Present Mild Somewhat Severe Severe Visual PerceptionPlease assess your child’s signs and/or symptoms in the following areasDifficulty sustaining visual attention Not Present Mild Somewhat Severe Severe Turning or tilting the head when writing or reading Not Present Mild Somewhat Severe Severe Loses place when reading or uses finger as a guide Not Present Mild Somewhat Severe Severe Moves head excessively when reading Not Present Mild Somewhat Severe Severe Difficulty copying from the board or a book Not Present Mild Somewhat Severe Severe Cannot see the differences in letters/numbers when writing or reading Not Present Mild Somewhat Severe Severe Dislikes hidden pictures, word searches or locating an object within a busy background Not Present Mild Somewhat Severe Severe Trouble finding a familiar object when it’s presented in an unfamiliar way Not Present Mild Somewhat Severe Severe Difficulty remembering, identifying and reproducing shapes Not Present Mild Somewhat Severe Severe Eye TeamingPlease assess your child’s signs and/or symptoms in the following areasRed, itchy, burning or watery eyes/excessive blinking or eye rubbing Not Present Mild Somewhat Severe Severe Red Not Present Mild Somewhat Severe Severe Itchy Not Present Mild Somewhat Severe Severe Burning Not Present Mild Somewhat Severe Severe Watery Eyes Not Present Mild Somewhat Severe Severe Excessive Blinking Not Present Mild Somewhat Severe Severe Eye Rubbing Not Present Mild Somewhat Severe Severe Closes or covers an eye Not Present Mild Somewhat Severe Severe Occasionally sees double Not Present Mild Somewhat Severe Severe Able to read for only a short time Not Present Mild Somewhat Severe Severe Complains of ‘blurred’ vision Not Present Mild Somewhat Severe Severe Has headaches when reading Not Present Mild Somewhat Severe Severe Says eyes are ‘tired’ Not Present Mild Somewhat Severe Severe Places head too close to book or desk when writing or reading Not Present Mild Somewhat Severe Severe SENSORYPlease assess your child’s signs and/or symptoms in the following areasSensitive to noise Not Present Mild Somewhat Severe Severe Sensitive to light Not Present Mild Somewhat Severe Severe Sensitive to smell Not Present Mild Somewhat Severe Severe Sensitive to taste Not Present Mild Somewhat Severe Severe Sensitive to touch Not Present Mild Somewhat Severe Severe Sensitive to textures/tags in clothing Not Present Mild Somewhat Severe Severe Sensitive to waistband in pants Not Present Mild Somewhat Severe Severe Sensory disorder diagnosis Not Present Mild Somewhat Severe Severe Emotional/ BehavioralPlease assess your child’s signs and/or symptoms in the following areasStruggles with emotions Not Present Mild Somewhat Severe Severe Struggles with anxiety Not Present Mild Somewhat Severe Severe Struggles with insecurity Not Present Mild Somewhat Severe Severe Struggles with fight or flight Not Present Mild Somewhat Severe Severe Struggles with meltdowns Not Present Mild Somewhat Severe Severe Struggles with anger/aggression Not Present Mild Somewhat Severe Severe Struggles with panic attacks Not Present Mild Somewhat Severe Severe Struggles with accepting or giving affection Not Present Mild Somewhat Severe Severe Struggles with depression Not Present Mild Somewhat Severe Severe Struggles with impulse control Not Present Mild Somewhat Severe Severe Struggles adapting to change/new situations/ information Not Present Mild Somewhat Severe Severe Fearful Not Present Mild Somewhat Severe Severe AttentionPlease assess your child’s signs and/or symptoms in the following areasChallenges with fidgeting Not Present Mild Somewhat Severe Severe Challenges with distractibility Not Present Mild Somewhat Severe Severe Challenges with sitting still/properly in chair Not Present Mild Somewhat Severe Severe Challenges with concentration Not Present Mild Somewhat Severe Severe Challenges with hyperactivity Not Present Mild Somewhat Severe Severe ADHD diagnosis Not Present Mild Somewhat Severe Severe (please rate severity) VisualPlease assess your child’s signs and/or symptoms in the following areasDifficulty copying from board Not Present Mild Somewhat Severe Severe Poor visual attention Not Present Mild Somewhat Severe Severe Blurry or double vision Not Present Mild Somewhat Severe Severe Rubbing or reddening of eyes Not Present Mild Somewhat Severe Severe Difficulty tracking Not Present Mild Somewhat Severe Severe AuditoryPlease assess your child’s signs and/or symptoms in the following areasDifficulty following directions Not Present Mild Somewhat Severe Severe Difficulty with background noise Not Present Mild Somewhat Severe Severe Auditory processing issues Not Present Mild Somewhat Severe Severe Auditory confusion or overload Not Present Mild Somewhat Severe Severe SocialPlease assess your child’s signs and/or symptoms in the following areasDifficulty making eye contact Not Present Mild Somewhat Severe Severe Shyness Not Present Mild Somewhat Severe Severe Prefers isolation Not Present Mild Somewhat Severe Severe Uncomfortable in social situations/socially immature Not Present Mild Somewhat Severe Severe Speech/ CommunicationPlease assess your child’s signs and/or symptoms in the following areasDifficulty expressing thoughts Not Present Mild Somewhat Severe Severe Speech disorder diagnosis Not Present Mild Somewhat Severe Severe Stuttering Not Present Mild Somewhat Severe Severe Oral IssuesPlease assess your child’s signs and/or symptoms in the following areasMovement of mouth when writing Not Present Mild Somewhat Severe Severe Placing objects in mouth (chewing on shirt, pencils, fingers, etc.) Not Present Mild Somewhat Severe Severe Thumb sucking Not Present Mild Somewhat Severe Severe Nail biting Not Present Mild Somewhat Severe Severe Messy eater Not Present Mild Somewhat Severe Severe Gross MotorPlease assess your child’s signs and/or symptoms in the following areasDifficulty with balance Not Present Mild Somewhat Severe Severe Low endurance Not Present Mild Somewhat Severe Severe Low/weak muscle tone Not Present Mild Somewhat Severe Severe Ape-like walk Not Present Mild Somewhat Severe Severe Clumsy Not Present Mild Somewhat Severe Severe Difficulty with/can’t ride a bike Not Present Mild Somewhat Severe Severe Poor hand-eye coordination Not Present Mild Somewhat Severe Severe Uncoordinated Not Present Mild Somewhat Severe Severe Abnormal gait Not Present Mild Somewhat Severe Severe Difficulty with running/swimming Not Present Mild Somewhat Severe Severe Poor posture Not Present Mild Somewhat Severe Severe Walks on toes Not Present Mild Somewhat Severe Severe Sits in W position Not Present Mild Somewhat Severe Severe Fine MotorPlease assess your child’s signs and/or symptoms in the following areasPoor handwriting Not Present Mild Somewhat Severe Severe Difficulty tying shoes/doesn’t like wearing shoes Not Present Mild Somewhat Severe Severe Difficulty with buttons/zippers Not Present Mild Somewhat Severe Severe Poor pencil grip Not Present Mild Somewhat Severe Severe Too much pencil pressure when writing Not Present Mild Somewhat Severe Severe Difficulty using utensils: knife, spoon, fork Not Present Mild Somewhat Severe Severe OtherPlease assess your child’s signs and/or symptoms in the following areasWets the bed/poor bladder control Not Present Mild Somewhat Severe Severe Poor short-term memory Not Present Mild Somewhat Severe Severe Poor long-term memory Not Present Mild Somewhat Severe Severe Slow processing speeds Not Present Mild Somewhat Severe Severe Poor sleep Not Present Mild Somewhat Severe Severe Frequent reversals Not Present Mild Somewhat Severe Severe Dyslexia Not Present Mild Somewhat Severe Severe Math difficulties Not Present Mild Somewhat Severe Severe Spelling difficulties Not Present Mild Somewhat Severe Severe Reading difficulties Not Present Mild Somewhat Severe Severe GoalsPlease list the goals for your child as it relates to their time with Scribble 2 Script.1st Goal2nd Goal3rd Goal Δ
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