PHYSICAL THERAPY AND OCCUPATIONAL THERAPY
SCREENING CHECKLIST
*Complete this checklist prior to making an OT/PT referral. Give completed checklist to the
appropriate OT or PT. Therapist will assist in determining if a referral is needed.
STUDENT:_______________________________ COMPLETED BY:_________________
SCHOOL:________________________________ DATE COMPLETED:_______________
D.O.B.:__________________________________ GRADE:________________________
OCCUPATIONAL THERAPY
PHYSICAL THERAPY
Fine Motor Skills:
Gross Motor Skills:
Visual Motor/Visual Perceptual Skills:
Gait:
difficulty opening containers
slow/difficult manipulation of objects
poor hand/finger strength
uses awkward/unusual grips/pinches
other___________________________
poor pencil grip
unable to print or poor legibility
difficulty copying material
other___________________________
Sensory Integration/Processing:
defensive to touch, doesn’t like to touch
certain materials
exhibits self-stimulating behavior
clumsy, poor planning of movement
other___________________________
Self-Care Skills:
difficulty with running, jumping, hopping
difficulty with ball skills: catching, kicking
poor sitting balance in chair, on floor
poor performance in p.e. class or on
playground
fatigues easily/becomes short of breath
stiff/inflexible
weak/poor posture
complaints of pain
other___________________________
difficulty walking: awkward gait, walks on
toes, falls frequently
difficulty with stairs on bus, curbs, etc.
other___________________________
Equipment:
needs training in wheelchair propulsion,
transferring in/out of chair
needs positioning equipment for classroom
needs equipment for standing/walking
needs special bathroom equipment
uses walker, crutches, foot/leg orthotics
equipment in need of repair
other___________________________
difficulty with self-feeding
difficulty with dressing, clothing fasteners
difficulty accessing items in environment
other___________________________
Oral Motor Skills:
difficulty with or unable to chew
chokes easily
drooling present, poor lip closure on spoon
or cup
other___________________________
Comments/primary reason for referral to OT or PT:____________________________________
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