Assessment
Checklist on
Different Child’s
Difficulty
Assessment Checklist on Difficulty in Seeing
Totally Blind
Characteristics
1. Lack of usable vision.
2. Receive no stimuli from their
visual channel.
3. Depend entirely on input from
other senses such as touch,
hearing, smelling, and tasting.
4. The sense of touch is very keen.
5. Move slowly and carefully due to
the fear of bumping into things
or objects.
6. Move, feel, and touch objects,
especially when traveling, to
ensure they are on the right
path.
7. Lack of light perception.
8. Use
tactile
and
auditory
channels for learning and
functional tasks.
9. Use cane for mobility.
10. Learn via Braille and other nonvisual media.
Yes/No
Remarks
Intervention
Low Vision/Partially-sighted
Characteristics
Yes/No
1. Have vision between 20/7020/160 and cannot be
corrected.
2. Use correctional glasses and
3. contact lenses.
4. Uses tactile and auditory
channels for learning.
Screened by:
___________________________
Signature over printed name
Date: _____________
Remarks
Intervention
Assessment Checklist on Difficulty in
Basic Learning and Applying Knowledge
Characteristics
Yes/No
1. Difficulty learning connections
between letters and sounds
2. Confused in short words (at and
to)
3. Letter reversals
4. Word reversals
5. Frequently adds and/or forgets
letters in a word
6. Difficulty
in
remembering
simple sequences
7. Difficulty keeping in place when
reading
8. Poor sequencing of numbers
9. Poor spelling
10. Avoids reading aloud
11. Difficulty organizing ideas to
speak or write
12. Avoids writing tasks
13. Left and Right confusion
14. Slow to memorize tasks and
math
15. Trouble
following
instructions
16. Appearing
distracted
restless
17. Difficulty in reading
or
oral
easily
Remarks
Intervention
18. Difficulty in writing
19. Difficulty in spelling
20. Difficulty in
calculating
counting
and
Screened by:
___________________________
Signature over printed name
Date:
_______________________
Assessment Checklist on Difficulty in
Remembering and Concentrating
Physical and Motor Characteristics
Characteristics
1. Is slightly lighter in weight than
most children of his/her own
group
2. Is shorter in height than most
children of his/her own age
group
3. Walks with stooping shoulders
4. Walks
with
uncoordinated
swaying of the arms
5. Tendency to trip or stumble over
objects while walking
6. Tendency to drop objects and
articles
7. Has difficulty in maintaining
balance while jumping, hopping,
and skipping
8. Has difficulty in using scissors
9. Has difficulty in using knives for
slicing, paring, and cutting
10. Finds
difficulty
in
tying
shoelaces, ribbons or sash
11. Is unable to hold pen or pencil
correctly
12. Has difficulty in tracing circle,
square and triangle
13. Has difficulty in drawing a circle
14. Has difficulty in drawing triangle
Yes/No
Remarks
Intervention
15. Has difficulty in drawing square
16. Has difficulty in writing letters of
the alphabet
17. Finds
difficulty
numbers
in
writing
18. Has the following physical
deformities
 Dry, course and scaly skin
● Slanted
eyes
with
coordinated eye muscles
● Protruding forehead
●
Large protruding tongue
●
Wide face
●
●
Disproportionately short
hands and fingers
Broad hands with fingers
having square ends
Teeth that are peg shaped
and chalky
Swollen eyelids and eyes
that are half-shut
Short thick neck
●
Short thick legs
●
Large head
●
Disproportionately
head
●
●
●
small
Personal and Social Characteristics
Characteristics
Yes/No
Remarks
Intervention
1. Tendency to be alone most of the
time
2. Easily cries
3. Tendency to get angry at a slight
provocation
4. Lacks concern and attention to
events and people around him
5. Talks and laughs in
unnecessarily loud voice
an
6. Tendency to over react to events
and people around him
7. Does not care about the feelings
of others
8. Does not laugh easily when
confronted
with
funny
situations
Learning Characteristics
Characteristics
Yes/No
1. Has short attention span
2. Has poor memory
3. Has difficulty in comprehending
situations in communication
4. Is easily
him/her
distracted
around
5. Has difficulty in finishing work
that has been started
6. Perseverates
or
unnecessary action
repeats
Remarks
Intervention
7. Has reversals in written work
8. Has difficulty in relating isolated
facts into meaningful ideas
Spoken Language
Characteristics
Yes/No
1. Refuses to talk
2. Has the tendency to speak in
words or phrases instead
3. Tendency to talk in sentences
with grammatical errors
4. Has immature
vocabulary
or
improper
5. Tendency to have articulation
problems such as:
a. omissions
b. substitutions
c. additions
d. additions
6. Gropes for words to express
himself
Screened by:
___________________________
Signature over printed name
Date: ________________________________
Remarks
Intervention
Assessment Checklist on Difficulty in Performing
Adaptive Skills
Characteristics
Yes/No
1. Difficulty in dealing with other
children
2. Acts as deaf
3. Resists learning
4. No fear of real dangers
5. Resists change in routine
6. Indicates need by gesture
7. Inappropriate
giggling
laughing
and
8. Not cuddly
9. Marked physical over activity
10. No eye contact
11. Inappropriate attachments to
objects
12. Spins objects
13. Sustained odd play
14. Standoffish manner
15. High pain tolerance
Remarks
Intervention
Characteristics on Conceptual Skills
Characteristics
Yes/No
Remarks
Intervention
1. Seems
forgetful,
easily
distracted or daydreaming
2. Appears not to listen and has
trouble following directions
3. Interrupts people, blurts things
out inappropriately and may
struggle with nonverbal cues
4. Acts without thinking and may
not
understand
the
consequences of his actions
5. Has obsessive interests
experiences perseveration
and
6. Disobey rules and policies
7. Fails to finish school works
8. Does not seem to listen when
spoken to
9. Fall asleep easily in class
Characteristics on Social Skills
Characteristics
Yes/No
1. Struggles with organization and
completing tasks
2. May overreact to sensory input,
like the way things sound,
smell, taste, look or feel
3. Gets upset
routine
by
changes
in
4. Reacts strongly to the way
things sound, smell, taste, look
Remarks
Intervention
or feel
issues)
(sensory
processing
5. Difficulty
working
independently in daily chores
6. Uses
eating
inappropriately
utensils
7. Unable to put on shoes by
himself
8. Unable to fold clothes
9. Difficulty in preparing simple
meals
Screened by:
___________________________
Signature over printed name
Date: ________________________________
Assessment Checklist on Difficulty in Displaying
Interpersonal Behavior
Characteristics
Yes/No
1. Bullies
and
threatens
classmates and others
2. Initiates physical fights
3. Has little empathy for others
and has lack of appropriate
feelings of guilt
4. Lies to peers or teachers
5. Steals from peers or the school
6. Shows
fearfulness
apprehension
and
7. Has
difficulty
mingling/interacting
others
in
with
8. Has low self-esteem masked by
showing boldness intended to
impress or intimidate
9. Afraid of
activities
consequences
10. Constantly seeks
from others
of
affirmation
11. Deliberately annoys others
12. Worries about things that might
happen or have happened
13. Criticizes self and others
14. Avoids things or places or
refuses to do things or go places
Remarks
Intervention
15. Expresses
feelings
of
worthlessness, hopelessness
16. Blames self and others for one’s
mistakes or misbehavior
17. Has
lack
of
interest
classroom/school activities
in
18. Thinks or talks repeatedly of
suicide
19. Afraid of failure, rejection and
embarrassment
20. Avoids work activities that
involve contact with others
21. Avoids work activities that
involve contact with others
22. Has the tendency to use and
abuse prohibited drugs and
alcohol
23. Defies and refuses to comply
with
rules
and
teacher's
requests
Screened by:
___________________________
Signature over printed name
Date: ________________________________
Difficulty in Speech and Language
Characteristics
Yes/No
Usually has no speech
If he has spoken, he…
●
Uses limited vocabulary
●
●
Speaks in words instead of
sentences
Is particularly poor in
spelling
Is poor in dictation
●
Talks with poor rhythm
●
Screened by:
___________________________
Signature over printed name
Date: ________________________________
Remarks
Intervention