OCT5255 Clinical Applications of OT in Pediatrics/Adolescence
Evaluation Form
OCCUPATIONAL THERAPY EVALUATION
Child Name:
Date(s) of Assessment:
Date of Birth:
Age at Testing:
Examiner:
School/Grade (if appropriate):
Date of Report:
Referral Information and Relevant History
Reason for referral:
Client concerns related to occupation:
Specific referral questions to be addressed in this evaluation include:
Relevant Medical/Educational History (Suggested Sources: 1. AOTA 2015 Background Information and Family Occupational
History Information Form, 2. Information from Complex Case, 3. AOTA Occupational Profile Template).
Primary Language:
Secondary Language:
Assessment Situation *This section does not need to be completed for Signature Assignment and Clinic submission
Discuss the context in which the assessment took place and its impact on the child’s performance. 



( Level of impact of the environmental factor on participation and performance: N=No impact; Min=Minimal impact;
S=Significant impact)
Environmental Factor
N Min
S
Description of factor and how it impacts participation and performance in
activities
Physical layout of Space
Organization of
materials/supplies
Availability/Clarity of
Performance Expectations
Noise level
Visual stimuli
Lighting
Number of individuals present
Temperature
Other:
Were standardized evaluation procedures adhered to during the evaluation session? _____yes
____no
If not, how were procedures modified?
__ Parent/Caregiver Interview
__ Clinical Observations
__Teacher Interview
__ Record Review
__Classroom Observation
Information Sources for Evaluation
__Ages and Stages Questionnaire
__Peabody Developmental Motor
Scales-2nd ed.
__Miller Function and Participation
Scales
1
__Wide Range Assessment of
Visual Motor Abilities
__Beery Buktenica Test of Visual
Motor Integration (VMI)
OCT5255 Clinical Applications of OT in Pediatrics/Adolescence
Evaluation Form
__Functional Educational Checklist
__Interest Checklist
__Other: ____________________
__Bruininks-Oseretsky Test of
Motor Proficiency, 2nd ed.
__Short Child Occupational Profile
__Evaluation Tool of Children’s
Handwriting
__Sensory Profile
__Sensory Processing Measure
Additional Sources of Information: (reports from other providers, eg. speech and language report, physical
therapy report, neurologist report, psychologist report).
Objective Data
Provide the name and brief description of the assessment(s) and all relevant scores and objective findings.
Clinical Observations
Behavior During Testing: Describe the child’s overall behavior and participation during testing including psychosocial factors, eg.
attention, emotional regulation, joint attention and social interactions with examiner. Was the child’s performance an accurate
representation of skill level?
Parent/Caregiver interview or direct clinical observation: (gather data regarding priorities, concerns, routines, habits and roles)
Adaptive Self-help:
Play:
Social Participation:
Educational Participation:
Quality of Movement (neuromotor control of coordination, range of motion, posture, muscle tone, strength, endurance, static/dynamic
balance)
Gross Motor: (includes all developmental or discrete motor skills and functional mobility)
Fine Motor: (includes grasp and release; manipulation skills; bimanual and bilateral coordination; eye-hand coordination)
2
OCT5255 Clinical Applications of OT in Pediatrics/Adolescence
Evaluation Form
Visual Perception/Visual Motor Integration: (early literacy, hand dominance, pre-handwriting and handwriting, written expression,
and subsets of visual perception)
Sensory Processing: (this is specific to any data formally gathered from assessments and/or data gathered from clinical observation
and parent interview. Can include tactile, vestibular, proprioception awareness, auditory, visual, spatial-temporal skills, and oral
sensory).
Praxis: (motor planning, sequencing, cognition, executive functioning, and use of language)
Impressions
Synthesis of objective data to inform impression statement. This should include an in depth, succinct synthesis of evaluation findings
related to performance skills, client factors and/or contextual variables as they relate to the occupations of childhood. Synthesis must
include age, child’s strengths, and reason for referral, and presenting occupational concerns.
________is a __________ old boy/girl referred for an occupational therapy evaluation for___________________. Results of this
assessment indicate _______________________________________________________________________________________.
Recommendations and Plan
The child will benefit from occupational therapy services to address _______ (fine motor skills, bimanual coordination, praxis, etc).
(frequency, duration and intensity of services)
OR
The child does not require occupational therapy services at this time, however recommendations were provided to family to support
caregiver concerns.
Additional recommendations: Provide recommendations to support/enhance occupational performance and/or child development.
(eg. non competitive extracurricular activities, referral to speech and language evaluation, ENT, Optometry, etc).




Intervention Plan: Provide a brief intervention plan.
Goals:
Baseline
LTG
STG 1
STG2
Baseline
LTG
STG1
3
OCT5255 Clinical Applications of OT in Pediatrics/Adolescence
Evaluation Form
STG2
Baseline
LTG
STG 1
STG2
Types of Interventions:
Occupations and Activities
Play
Social Participation
Fine motor
Preparatory Methods and
Tasks
Education and Training
Caregiver
education/coaching
Examiner Signatures:
4
Advocacy
Group