Physical Therapy
TEACHER CHECKLIST
For Screening
Student: ___________________ Date: __________ Date of Birth: __________
Teacher: ___________________ School: _________ Class: ________________
Strength/ Endurance
____ Seems weak
____ Gets tired easily, has low endurance
In the Classroom
____ Doesn’t sit in chair correctly, sits awkwardly
____ Has difficulty getting down to or getting up from the floor
____ Has difficulty sitting on floor, leans on objects or others
____ Has difficulty hanging up and taking down bookbag and/or coat
Walking
____ Leans on people, wall or furniture when walking
____ Is clumsy or awkward, or tends to trip or fall down
____ Has difficulty keeping pace with classmates
____ Is afraid or has difficulty going up/ down stairs
Activities Outside the Classroom
____ Reluctant to participate in physical activity
____ Has difficulty opening doors
____ Has difficulty carrying bag, backpack
____ Unable to carry or balance lunch tray
____ Has difficulty getting on/off bus
____ Has difficulty with running, jumping, throwing, catching or kicking (encircle)
Level of Concern
Please indicate your level of concern about the above difficulties.
____ Mildly concerned ____ Moderately concerned ____Extremely concerned
You can also use the space below for comments or to add any other physical
difficulties you have observed. Thank you.
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