Motorvate Kids

Child's date of birth *

MM

DD

YYYY

Referral Type:

Medical Professional

School

Friend / Family

Web Search / Website

Special Needs Group

Social Media

Other

Name of Person Completing This Form *

First Name

Last Name

Phone *

(###)

###

####

Difficulty riding a riding toy, with feet pushing or propelling *

Yes, Frequently

Sometimes

Never

Difficulty or hesitancy in climbing up and/or down stairs alternating feet *

Yes, frequently

Sometimes

Never

Dislikes playing with puzzles *

Yes, frequently

Sometimes

Never

Dislikes or avoids coloring or drawing *

Yes, frequently

Sometimes

Never

Dislikes playing with small manipulative toys (such as Legos, beads, or blocks) *

Yes, frequently

Sometimes

Never

Difficulty with the use of a spoon or cup *

Yes, frequently

Sometimes

Never

Has very messy eating habits *

Yes, frequently

Sometimes

Never

Seems weaker or tires more easily than other children of the same age *

Yes, frequently

Sometimes

Never

Appears stiff, awkward, or clumsy in movement *

Yes, frequently

Sometimes

Never

Difficulty learning new motor tasks *

Yes, frequently

Sometimes

Never

Has difficulty getting on coat with zipper or putting on shoes (not tying) *

Yes, frequently

Sometimes

Never

Uses too much force when playing with toys or interacting with children or pets *

Yes, frequently

Sometimes

Never

Walks on toes, now or in the past *

Yes, frequently

Sometimes

Never

Child appears to be in constant motion, unable to sit still for an activity *

Yes, frequently

Sometimes

Never

Appears fearful of going down stairs *

Yes, frequently

Sometimes

Never

Gets nauseated or vomits from other movement experiences (such as swings, merry-go-rounds, etc.) *

Yes, frequently

Sometimes

Never

Seeks quantities of twirling or spinning *

Yes, frequently

Sometimes

Never

Needs quantities of stimulation on amusement park rides and swings *

Yes, frequently

Sometimes

Never

Hesitates to climb or play on playground equipment *

Yes, frequently

Sometimes

Never

Has trouble or hesitancy in learning to catch a ball *

Yes, frequently

Sometimes

Never

Dislikes active running games (such as tag) *

Yes, frequently

Sometimes

Never

Rocks himself / herself or bangs head when stressed *

Yes, frequently

Sometimes

Never

Seems to fall frequently *

Yes, frequently

Sometimes

Never

Has poor safety awareness when moving through space *

Yes, frequently

Sometimes

Never

Fearful of going down a slide or swing *

Yes, frequently

Sometimes

Never

Seems unaware of being touched or bumped *

Yes, frequently

Sometimes

Never

Seems overly sensitive to being touched, pulls away from light touch *

Yes, frequently

Sometimes

Never

Has trouble remaining in busy or group situations (such as circle time or recess) *

Yes, frequently

Sometimes

Never

Complains that clothing is uncomfortable and/or bothered by the tags in the back *

Yes, frequently

Sometimes

Never

Resists wearing short-sleeved shirts or short pants *

Yes, frequently

Sometimes

Never

Continues to examine objects by putting in the mouth (past the age of 18 months) *

Yes, frequently

Sometimes

Never

Dislikes being cuddled / hugged unless on child's terms *

Yes, frequently

Sometimes

Never

Seeks quantities of jumping and crashing *

Yes, frequently

Sometimes

Never

Avoids putting hands in messy substances (such as Play-Doh, finger paint, or glue) *

Yes, frequently

Sometimes

Never

Is a picky eater, refuses many foods *

Yes, frequently

Sometimes

Never

Pinches, bites, or otherwise hurts self *

Yes, frequently

Sometimes

Never

Often unaware of bruises and cuts until someone calls it to his/her attention *

Yes, frequently

Sometimes

Never

Seems overly sensitive to slight bumps or scrapes *

Yes, frequently

Sometimes

Never

Tends to touch things constantly *

Yes, frequently

Sometimes

Never

Frequently pushes or hits other children *

Yes, frequently

Sometimes

Never

Has or had repeated ear infections *

Yes, frequently

Sometimes

Never

Particularly distracted by sounds, seeming to hear sounds that go unnoticed by others *

Yes, frequently

Sometimes

Never

Doesn't respond consistently to verbal cues *

Yes, frequently

Sometimes

Never

Is overly sensitive to mildly loud noises (such as bells or toilet flush) *

Yes, frequently

Sometimes

Never

Is hard to understand when she/he speaks *

Yes, frequently

Sometimes

Never

Has trouble following 1-2 step commands *

Yes, frequently

Sometimes

Never

History of delayed speech development *

Yes, frequently

Sometimes

Never

Late in achieving bowel and bladder control *

Yes, frequently

Sometimes

Never

Occasionally has accidents during the day *

Yes, frequently

Sometimes

Never

If accidents occur, child does not seem to be aware *

Yes, frequently

Sometimes

Never

Does not accept changes in routine easily *

Yes, frequently

Sometimes

Never

Becomes easily frustrated *

Yes, frequently

Sometimes

Never

Apt to be impulsive, heedless, accident-prone *

Yes, frequently

Sometimes

Never

Has frequent outbursts or tantrums *

Yes, frequently

Sometimes

Never

Tends to withdraw from groups; plays on the outskirts *

Yes, frequently

Sometimes

Never

Has trouble making needs known in appropriate manner *

Yes, frequently

Sometimes

Never

Avoids eye contact *

Yes, frequently

Sometimes

Never