Occupational Therapy Developmental Checklist
Please complete this short screening to learn if your child's occupational development is on track with his/her age.
Name of person completing the checklist:
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First Name
Last Name
Relationship to child:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email (Results from screening will be sent to email provided):
*
example@example.com
Where did you receive this free screening flyer?
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Child's Name:
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First Name
Last Name
Child's Date of Birth:
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-
Month
-
Day
Year
Date
Child's Gender:
Female
Male
Has had two or more ear infections?
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Yes
No
Do you have concerns about your child's occupational development (sensory processing, emotional regulation, frustration tolerance, self help skills, fine and/or gross motor skills)?
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Yes, I have concerns
No, I think my child is on track for his/her age
I'm not sure
Age of Child:
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1 year to 1 year 11 months
2 years to 2 years 11 months
3 years to 3 years 11 months
4 years to 4 years 11 months
5 years to 5 years 11 months
6 years to 6 years 11 months
My 1 year old child (check all that apply):
Crawls on hands and knees
Walks along furniture
Stands without support from parent or furniture
Releases objects into a container with a large opening
Feeds self finger foods
Picks up small objects using tip of thumb and index finger
Points to things they want
Follows simple 1 step directions (ex., go get your cup)
Uses at least 10 different words
Tries new foods
My 2 year old child (check all that apply):
Imitates vertical, horizontal and circular marks
Completes 3-piece insert puzzle
Holds and snips with scissors
Begins to throw and kick ball with little accuracy
Jumps down from step
Walks up and down stairs without support (2-2.5 yrs.)
Good use of spoon; beginning to use fork
Able to remove coat when unfastened; helps pull down pants; locates armholes in shirt
Participates in bathing self; assists in brushing teeth; may see some resistance to grooming
Begins to show interest in toileting
My 3 year old child (check all that apply):
Copies a vertical line, horizontal line and circle
Jumps with two feet off floor
Puts on pull over shirt with minimal assistance
Begins to throw and kick ball with little accuracy
Puts on shoes without fasteners (may be on wrong foot)
Puts on socks (may be with heel on top)
Zips and Unzips once latched
Buttons large front buttons
Participates in bathing self; assists in brushing teeth; may see some resistance to grooming
Begins to show interest in toileting
My 4 year old child (Check all that apply):
Child grasps writing tools with index, middle and long fingers
Child attempts to color within the lines
Draws a person with a head, body, arms and legs
Cuts straight lines and attempts more complex shapes (i.e. square, triangle, diamond)
Puts together simple puzzles of 4-12 pieces
Child is able to feed themselves with little mess
Independently uses utensils (i.e. fork, spoon)
Catches a bouncing ball
Stands on one foot for 2-3 seconds
Jumps on two feet in place
My 5 year old child (Check all that apply):
Child grasps writing tools using their index, middle and long fingers
Pre-writing skills includes copying a vertical & horizontal line, circle, cross, square and a triangle
Cutting skills are becoming more proficient as child is able to cut out more complex shapes
Prints name and familiar letters from memory
Copies all letters of the alphabet
Draws a person with 2-4 body parts
Fastens Velcro shoes, buttons and zippers
Stands on one foot for 5 seconds
Throws a ball overhand with direction
May be able to skip
My 6 year old child (Check all that apply):
Draws more complex shapes and designs (triangle, diagonal lines)
Draws recognizable and meaningful pictures
Draws a person with at least six body parts
Cuts out more complex shapes
Builds three dimensional block structures
Child prints name, all capital and lower case letters, and numbers
Stands on one foot for 10 seconds
Hops on one foot consecutively
Throws and catches a small ball with increased control and accuracy
Stands on one foot for 10 seconds
If you have any area of concern with your child's sensory issues, fine and/or gross motor skills, or are wondering if something is "typical", please describe.
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