Occupational Therapy Questionnaire
Childs Name
*
First Name
Last Name
Self-Care Tasks
Dressing
Shoes on
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Shoes off
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Shirt on
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Shirt off
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Pants on
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Pants off
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Socks on
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Socks off
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Bathing
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Toileting
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Brushing Teeth
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Brushing Hair
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Nail Clipping
*
independent (no help needed)
minimum assistance needed (25%)
moderate assistance needed (50%)
maximum assistance needed (75%)
dependent on assistance (100%)
Play Skills
Does your child initiate play with others?
*
Yes
No
Does your child share?
*
Yes
No
Can your child take turns?
*
Yes
No
Comments:
Submit
Should be Empty: