Occupational Therapy Pediatric Evaluation Activities of

 

  Occupational Therapy Pediatric Evaluation  Activities of Daily Living Checklist    

Childs Name:_________________________  Filled out by:________________________  Date:______________________  Date of Birth:_______________  Chronological Age:__________    Please check the level of assistance your child requires for each task.        25%  50%  75%  Dependent    With Verbal  Assistance  Assistance  Assistance    Prompts        Independent    Feeding:  Finger feeds         __________          __________          __________          __________          __________          __________  Can use spoon     __________          __________          __________          __________          __________          __________  Can use fork         __________          __________          __________          __________          __________          __________  Can use Knife       __________          __________          __________          __________          __________          __________  Drinks from   a cup                       __________          __________          __________          __________          __________          __________    Hygiene:  Washes hands      __________          __________          __________          __________          __________          __________  Dries hands           __________          __________          __________          __________          __________          __________  Brushes teeth       __________          __________          __________          __________          __________          __________  Washes hair          __________          __________          __________          __________          __________          __________  Brush hair              __________          __________          __________          __________          __________          __________  Uses toilet              __________          __________          __________          __________          __________          __________    Dressing:  Undershirt              __________          __________          __________          __________          __________          __________  Shirt                          __________          __________          __________          __________          __________          __________  Sweater                    __________          __________          __________          __________          __________          __________  Jacket                        __________          __________          __________          __________          __________          __________  Underpants             __________          __________          __________          __________          __________          _________ Pants                         __________          __________          __________          __________          __________          __________              Snow pants             __________          __________          __________          __________          __________          __________  Shoes                        __________          __________          __________          __________          __________          __________  Socks                         __________          __________          __________          __________          __________         __________

    25%    With Verbal  Assistance    Prompts    Independent 

50%  Assistance   

75%  Assistance     

Dependent

Hat                             __________          __________          __________          __________          __________         __________  Mittens                     __________          __________          __________          __________          __________          __________  Sequencing of   Steps                          __________          __________          __________          __________          __________         __________  Fasteners:  Buttons                     __________          __________          __________          __________          __________         __________  Zippers                      __________          __________          __________          __________          __________         __________  Belts                           __________          __________          __________          __________          __________         __________  Ties shoes                 __________          __________          __________          __________          __________        __________    Undressing:  Undershirt              __________          __________          __________          __________          __________          __________  Shirt                          __________          __________          __________          __________          __________          __________  Sweater                    __________          __________          __________          __________          __________          __________  Jacket                        __________          __________          __________          __________          __________          __________  Underpants             __________          __________          __________          __________          __________          __________  Pants                         __________          __________          __________          __________          __________          __________  Snow pants             __________          __________          __________          __________          __________          __________  Socks                         __________          __________          __________          __________          __________         __________  Shoes                         __________          __________          __________          __________          __________         __________  Hat                             __________          __________          __________          __________          __________         __________  Mittens                     __________          __________          __________          __________          __________          __________  Sequencing of   Steps                          __________          __________          __________          __________          __________         __________  Fasteners:  Buttons                     __________          __________          __________          __________          __________         __________  Zippers                      __________          __________          __________          __________          __________         __________  Belts                           __________          __________          __________          __________          __________         __________  Ties shoes                 __________          __________          __________          __________          __________        __________    Comments:_________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 

Occupational Therapy Pediatric Evaluation Activities of

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