Name
Chronological age
Developmental age
Diagnosis
: Muhammad Syauqi
: 3 y/o
: According to Denver II (Personal Social- 4 y/o) (fine motor- 4 y/o) (Language- meets age
development) (Gross Motor- 4.5 y/o)
:
ACTIVITY DAILY LIVING
NO.
ACTIVITY DAILY LIVING
1
SCORING
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
Grooming
Wash hand without help
1
2
3
4
5
Use hair brush without help
1
2
3
4
5
Comb own hair without help
1
2
3
4
5
Brush teeth without help
1
2
3
4
5
Bathing
Turns on and off water tab
1
2
3
4
5
Washes body thoroughly
1
2
3
4
5
Applies soap all over the body
1
2
3
4
5
Washes extremities and back
1
2
3
4
5
Washes/shampoo hair and rinse
cleans
Dries body thoroughly
1
2
3
4
5
1
2
3
4
5
Takes appropriate time/duration
for showering
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1= Unable to perform/ N/A
2= Maximal prompt
3= Moderate prompt
4= Minimal prompt/ Verbal prompt
5 = Fully independent
1.
Eating
Use hand
Use spoon/fork with safe
Bring food into mouth without
litter
Drink from open cup with safe
2.
3.
4.
Dressing
Takes shirt and pant by
himself/herself
Able to distinguishes between
FEEDBACK
Able to use hand independently.
Able to use spoon or fork
independently.
Able to bring food into mouth without
litter independently.
Able to drink from open cup with safe
independently.
Able to turn on and off and wash his
hand independently.
Able to use hair brush but need verbal
cue to remind him.
Able to comb his own hair but need
verbal cue to remind him comb on left
side, right side and at the back.
Able to brush his teeth but need verbal
prompt to mention brush on the side, up
and down.
Able to turn on and off water tab
independently.
Need to be remind to wash his body
thoroughly.
Need to be remind to applies soap over
the body.
Need verbal prompt to wash the
extremities and back during bathing.
Need verbal prompt to use shampoo
and wash hair.
Need verbal cue to keep remind him to
dries his body thoroughly.
Mother claimed he took a long time for
showering and need verbal prompt to
stop him from showering.
Need verbal cue to ask him to take pant
and shirt in his bag.
Able to determine between right and
right and left
Able to distinguishes between
front and back
Able to removes t-shirt/dress
Able to removes pants/trousers
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
Toileting
Takes self into toilet or bathroom
1
2
3
4
5
Takes self into clean afterwards
1
2
3
4
5
1
2
3
4
5
Independent.
1
2
3
4
5
Need some verbal prompt.
1
2
3
4
5
N/A – not use diapers anymore.
Independent.
1
1
2
2
3
3
4
4
5
5
Independent.
Independent.
1
1
2
2
3
3
4
4
5
5
Climbing stairs without holding
rails
Downstairs with holding rails
1
2
3
4
5
1
2
3
4
5
Downstairs without holding rails
1
2
3
4
5
Able to walk independently.
Able to climb stair with holding rails
independently.
Able to climb stair w/o holding rails
independently.
Able to do downstairs with holding
rails independently.
Able to do downstairs w/o holding
independently.
Able to puts on t-shirt/dress
Able to puts on pants/trousers
Snaps or unsnaps, Zips or unzips,
Buttons or unbuttons
5.
6.
7.
8.
left side during dressing.
Need minimal prompt to distinguishes
the garment between front and back.
Able to remove shirt independently.
Able to remove pants/trouser
independently.
Able to put on shirt independently.
Able to put on pant independently.
Need minimal assistance in buttoning
but independence in snap or unsnap, zip
or unzip and unbutton.
Bowel and Bladder
Urinate or open bowl on the
potty/toilet
Indicates need to urinate or open
bowl
Indicates when met in diapers
Transfer
Chair to bed
Bed to Chair
Locomotion
Walking
Climbing stairs with holding rails
Sometime he need verbal prompt such
as “you want go to the toilet?”
Able to clean himself afterwards
independently.
SHORT SENSORY PROFILE
SENSORY COMPONENT
SCORE
1=Always 2=Frequently 3=Occasionally 4=Seldom
5=Never
1
TACTILE SENSITIVITY
1.
Expresses distress during grooming (fights/cries during
haircutting, face washing, fingernail cutting)
2.
Prefers long-sleeved clothing when it is warm or short
sleeves when it is cold
3.
Avoid going barefoot, especially in sand or grass
4.
Reacts emotionally or aggressively to touch
5.
Withdrwas from splashing water
6.
Has difficulty standing in line or close to other people
7.
Rubs or scratches out a spot that has been touched
Section Raw Score
TASTE/ SMELL SENSITIVITY
1.
Avoid certain tastes or food smells that are typycally part
of children’s diets
2.
Will only eat certain tastes (list:___________________)
3.
Limits self to particular food textures/ temperatures
4.
Picky eater, especially regarding food textures
Section Raw Score
MOVEMENT SENSITIVITY
1.
Becomes anxious or distressed when feet leaves the
ground
2.
Fears falling or heights
3.
Dislikes activities where head is upside down (for
example somersaults, roughhousing)
4.
UNDERRESPONSIVE/ SEEK SENSATION
1.
Enjoy strange noises/ seeks to make noise for noise’s
sake
2.
Seeks all kind of movement and this interferes with daily
routines (can;t sit still, fidgets)
3.
Becomes overly excitable during movement activity
4.
Touches people and objects
5.
Doesn’t seem to notice when face or hands are messy
2
REMARKS
3
4
5
6.
Jumps from one activity to another so that it interferes
with play
7.
Leaves clothing twisted on body
Section Raw Score
AUDITORY FILTERING
1.
Is distracted or has trouble functioning if there is a lot of
noise around
2.
Appears to not hear what you say (eg: does not tune in to
what you say, appears to ignore you)
3.
Can’t work with background noise (fan, refrigerator)
4.
Has trouble completingtasks when the radio is on
5.
Doesnt respond when name is called but you know the
child’s hearing is OK
6.
Has difficulty paying attention
Section Raw Score
LOW ENERGY/ WEAK
1.
Seems to have weak muscles
2.
Tires easily especially when standing or holding
particular body position
3.
Has a weak grasp
4.
Can’t lift heavy objects (eg; weak in comparison to same
age children)
5.
Props to dupport self (even during activity)
6.
Poor endurance/ tires easily
Section Raw Score
VISUAL/ AUDITORY SENSITIVITY
1.
Responds negatively to unexpected or loud noises (eg;
cries or hides at noise from vacuum cleaner, dog barking,
haitdryer)
2.
Hilds hands over ears to protect ears from sound
3.
Is bothered by bright lights after others have adapted to
the lights
4.
Wathes everyone when they move around the room
5.
Covers ears or squints to protect eyes from light
.
Section Raw Score