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 *

(###)

###

####

Seems weaker or tires more easily than other children his / her age *

Yes, frequently

Sometimes

Never

Difficulty with hopping, jumping, skipping, or running compared to others his / her age *

Yes, frequently

Sometimes

Never

Appears stiff and awkward in movements *

Yes, frequently

Sometimes

Never

Clumsy or seems not to know how to move body; bumps into things *

Yes, frequently

Sometimes

Never

Tendency to confuse right and left body sides *

Yes, frequently

Sometimes

Never

Hesitates to climb or play on playground equipment *

Yes, frequently

Sometimes

Never

Reluctant to participate in sports or physical activity; prefers table activities *

Yes, frequently

Sometimes

Never

Seems to have difficulty learning new motor tasks *

Yes, frequently

Sometimes

Never

Difficulty pumping self on swing; poor skills in rhythmic clapping games *

Yes, frequently

Sometimes

Never

Poor desk posture (slumps, leans on arm, head too close to work, other hand does not assist) *

Yes, frequently

Sometimes

Never

Difficulty drawing, coloring, copying, cutting - avoidance of these activities *

Yes, frequently

Sometimes

Never

Poor pencil grasp; drops pencil frequently *

Yes, frequently

Sometimes

Never

Pencil lines are tight, wobbly, too faint or too dark; breaks pencil more often than usual *

Yes, frequently

Sometimes

Never

Tight pencil grasp; fatigues quickly in writing or other pencil and paper tasks *

Yes, frequently

Sometimes

Never

Hand dominance not well established (after age six) *

Yes, frequently

Sometimes

Never

Difficulty in dressing; clothing off or on, buttons, zippers, tying bows on shoes *

Yes, frequently

Sometimes

Never

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

Yes, frequently

Sometimes

Never

Has trouble keeping hands to self, will poke or push other children *

Yes, frequently

Sometimes

Never

Touches things constantly; "learns" through his / her fingers *

Yes, frequently

Sometimes

Never

Has trouble controlling his / her interactions in group games such as tag, dodgeball *

Yes, frequently

Sometimes

Never

Avoids putting hands in messy substances (clay, finger paint, paste) *

Yes, frequently

Sometimes

Never

Seems to be unaware of being touched or bumped *

Yes, frequently

Sometimes

Never

Has trouble remaining in busy or group situations; such as cafeteria or circle time *

Yes, frequently

Sometimes

Never

Fearful moving through space (teeter-totter, swing) *

Yes, frequently

Sometimes

Never

Avoids activities that challenge balance; poor balance in motor activities *

Yes, frequently

Sometimes

Never

Seeks quantities of movement including swinging, spinning, bouncing, and jumping *

Yes, frequently

Sometimes

Never

Difficulty or hesitance learning to climb or descend stairs *

Yes, frequently

Sometimes

Never

Seems to fall frequently *

Yes, frequently

Sometimes

Never

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

Yes, frequently

Sometimes

Never

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

Yes, frequently

Sometimes

Never

Difficulty naming or matching colors, shapes, or sizes *

Yes, frequently

Sometimes

Never

Difficulty in completing puzzles; trial and error placement of pieces *

Yes, frequently

Sometimes

Never

Reversals in words or letters after first grade *

Yes, frequently

Sometimes

Never

Difficulty coordinating eyes for following a moving object; keeping place in reading; copying from blackboard to desk *

Yes, frequently

Sometimes

Never

Appears overly sensitive to loud noises, such as bells or toilet flushes *

Yes, frequently

Sometimes

Never

Is hard to understand when she or he speaks *

Yes, frequently

Sometimes

Never

Appears to have difficulty in understanding or paying attention to what is said to him or her *

Yes, frequently

Sometimes

Never

Easily distracted by sounds; seems to hear sounds that go unnoticed by others *

Yes, frequently

Sometimes

Never

Has trouble following 2-3 step commands *

Yes, frequently

Sometimes

Never

Does not accept changes in routine easily *

Yes, frequently

Sometimes

Never

Becomes easily frustrated *

Yes, frequently

Sometimes

Never

Difficulty getting along with other children *

Yes, frequently

Sometimes

Never

Apt to be impulsive, heedless, accident-prone *

Yes, frequently

Sometimes

Never

Easier to handle in small group or individually *

Yes, frequently

Sometimes

Never

Marked mood variations, tendency to 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

Check all areas of difficulty

Reading

Math

Spelling

Distractable

Restless

Hyperactive

Slow Writer

Poorly Organized

Finishing Tasks

Following Directions

Remembering Information

Short Attention Span

How concerned are you about the above checked problems?

Not concerned

Slightly

Moderately

Very