TW2 - New Client Information

Rows	Yes	Sometimes	No	Not Observed	N/A
Falls off chair
Is unable to sit still in chair, or on floor
Awkward position or propping head when writing/reading
Sits on legs on legs/pulls legs onto chair
Has difficulty negotiating steps (up or down or uneven surfaces

Rows	Yes	Sometimes	No	Not Observed	N/A
Has difficulty with jumping, hopping, skipping, running
Avoids sports/physical activity; prefers sedentary activities
Has difficulty learning new motor tasks
Has difficulty with ball skills (throwing, catching, kicking)
Has difficulty with PE in school

Rows	Yes	Sometimes	No	Not Observed	N/A
Is easily distracted by visual input or sounds or does not seem to notice
Does not like touching items or touches too much
Seeks movement or tends to avoid movement activities
Demonstrates excessively active behavior
Demonstrates low activity level
Demonstrates difficulty attending or sitting still
Tends to overreact and/or have difficulty calming
Difficulty grading movements, uses too much or too little force
Walks on toes frequently
Frequently gives/requests hugs
Seems weaker or tires more easily than peers
Is destructive or "overly hard" on classroom materials or is rough during play
Is fearful of movement through space (swing, etc)
Craves or seeks excessive movement (jumping, bouncing, spinning)
Appears clumsy (bumps into or drops things; falls frequently)
Avoids balance activities (playground and playground equipment)
Takes frequent movement breaks eg. frequent trips to bathroom or cubby
Lies down on arms or slumps in chair
Appears weaker or to have less stamina than peers
Movements appear stiff of awkward

Rows	Yes	Sometimes	No	Not Observed	N/A
Has difficulty with cutting
has difficulty with drawing/writing
Awkward grip on pencil/crayon
Pressure too hard/too soft
Difficulty with pencil grip
Complains hand is tired
Difficulty with manipulation of small objects (drops small items frequently)
Still uses both hands (dominance not established)

Rows	Yes	Sometimes	No	Not Observed	N/A
Has difficulty with copying from the board
Has difficulty with printing
Has difficulty with cursive
Has difficulty with staying within the lines
Has difficulty with size of letters
Has difficulty with letter formation
Has difficulty with letter/number spacing
Has difficulty with letter/number reversals
Has difficulty with content of creative writing
Has difficulty with sequencing/organizing stories
Has difficulty with writing letters and/or numbers from memory
Has difficulty with spelling
Has difficulty with directional concepts (up, down, over, under)
Has difficulty with right/left discrimination
Doesn’t stabilize work with non-dominant hand

NEW CLIENT INFORMATION

Rows	Independent	Needs Assistance	Dependent
Takes off shoes and socks
Putting on shoes and socks
Taking off clothes
Putting on clothes
Fasteners (buttons, zippers)
Eating small foods (ie cheerios)
Eating with a spoon
Eating with a fork
Cutting with a knife
Drinking from a cup
Drinking from a straw
Toileting skills (cleaning himself)

Rows	Yes	No	Sometimes
Respond to his/her name?
Point to objects when asked?
Follow simple directions?
Get objects from another room when asked?
Point to body parts when asked?
Point to pictures in books when asked?
Answer simple questions?
Point to family members when asked?
Understand prepositions (in, on, under, next to)?
Understand color & size words (red, big/small)?
Engage in pretend/imaginary play?
Socialize/play with other children?
Repeat sounds/words when speaking?
Have difficulty learning/retaining new information?
Have difficulty learning/using new words?

Rows	Yes	Sometimes	No	Not Observed	N/A
Has difficulty with changes in daily routine
Has difficulty with transitions between activities
Has low frustration tolerance; displays "acting out" behavior
Decreased effort for non-preference tasks
Has poor impulse control; no sense of danger
Tends to withdraw from group; remains on periphery
Shows little awareness of other's reactions
Has difficulty getting along with peers
Frequently disrupts structured class activities
Tends to want to direct activities/routines
Has short attention span/easily distractible

Rows	Yes	Sometimes	No	Not Observed	N/A
Has difficulty establishing daily routines at beginning and end of day
Has difficulty during free play or independent work time
Has difficulty completing work within expected time
Completes work in impulsive or sloppy manner
Has difficulty keeping notebooks, desk, locker clean
Tends to easily lose things
Difficulty finding things in desk
Forgets homework or directions to a task

Rows	Yes	Sometimes	No	Not Observed	N/A
Can easily dress/undress self
Can zip/unzip and button/ unbutton clothing
Can used fork/spoon at meantime

Rows	Yes	Sometimes	No	Not Observed	N/A
Deletes parts of sentences when talking
Does not say the correct pronoun, verb tense, and/or deletes words when speaking
Difficulty starting a conversation
Difficulty staying on topic during conversations
Difficulty naming familiar objects
Gives "off the wall" answers
Talks in "circles" and/or perseverates on topics
Needs to act out versus verbally answering in order to explain or describe their thoughts
Has a hard time switching from one topic to another
Difficulty describing events and/or objects