Behavioral Evaluation Record

Behavioral Evaluation Record
Evaluation Directions:
1. The evaluation record booklet should be filled out initially and at the last session (18th session in many cases).
2. You will receive a total of two evaluation booklets before completion of your session.
3. Please fill out the first evaluation prior to your first day of activities. Please return the two completed evaluations to the Activities Coach prior to the re-testing dates.
4. The evaluation instructions are as follows: Please tick the behavior impression for each of the following items using a grading system of 0-10. 0 = does not apply and 10 = very severe.
Full Name

First NameLast Name
Person(s) filling out questionnaire

First NameLast Name
Date

MonthDayYear
Age
Gender

MaleFemale
Phone Number

Area CodePhone Number
Email
example@example.com
Psychological/Emotional Behaviors
Seems angry at times
Seems depressed
Is aggressive with others
Disliked by others
Has difficulty making friends
Shows poor self esteem
Sleeps excessively
Exhibits violent behavior
Exhibits immature behavior
Physically hurts self or others
Academic Skills
Disorganized
Poor math calculation skills
Poor math reasoning (work problem) skills
Exhibits poor language and/or vocabulary skills
Slow to begin and/or finish homework
Exhibits poor memory
Does not enjoy reading
Makes careless errors or mistakes
Poor reading comprehension
Poor work reading skills
Attention/Hyperactivity Behaviors
Exhibits difficulty remaining seated for meals
Exhibits difficulty remaining seated for homework
Fidgets excessively
Has difficulty finishing homework or conversation
Easily distracted
Acts before thinking
Interrupts or speaks out of turn
Makes careless mistakes
Impulsive behavior
Poor eye contact
Vestibular System
Exhibits poor balance
Exhibited delay in crawling, standing, and/or walking
Poor muscle tone (extremely flexible)
Experiences motion sickness
Dislike of heights, swings, carousels, escalators, elevators
Easily disoriented and/or poor sense of direction
Clumsy
Difficulty remaining still; may actively engage in movement such as spinning and/or rocking
Difficulties with space perception
Walks or walked on toes
Visual system
Misreading words
Missing or repeating words or lines
Slow reading
Needs to use finger or marker as a pointer
Inability to remember what has been read
Poor concentration
Letters which move, jump, or are poorly focused
Handwriting crooked, or slopes in different directions, letters are poorly balanced
Reading with one eye covered or sideways posture
Light sensitivity
Auditory System
You thought they had a hearing problem as an infant
Inability to sing in tune
Hypersensitive to sound
Misinterpretation of questions
Confusion of similar sounding words, frequent need to have words repeated
Inability to follow sequential instructions
Flat and monotonous voice
Hesitant speech
Weak vocabulary
Confusion or reversal of letters
Proprioception
Poor posture
Constant fidgeting or moving
Excessive desire to be held
May provoke fights to get sensory input
Hooks feet around desk for support
Poorly developed knowledge of where different body parts are in space
Bumps into things often
Poor balance
Rocks body or bangs head
Does not like heights
Tactile: Hypo-tactile
Hypo-tactile
Doesn't notice or respond when cut
High threshold of pain
Doesn't feel cold or hot
Craving contact sports
Doesn't notice when lying on an object
May provoke roughhousing or fighting
Not ticklish
Compulsive touching
Bull in china shop
Tactile: Hyper-tactile
Hypersensitivity
Dislike of sports
Dislike of being touched
Hates tags on clothes
Allergic skin reactions
Hates any makeup or jewelry
Poor temperature control
Does not like clothing on arms or legs
Low external pain threshold
Doesn't like to touch things
Taste and smell: Hypersensitive
Exhibits increased sensitivity to taste and smell
Gags at smell of certain foods
Avoids going to bathroom and may be at risk of wetting pants because they cannot stand smell of antiseptics used
Likes bland food
May avoid others, especially those with dirty or smelly clothes
Comments about parents' bad breath
May misbehave after floors have been polished or other cleaning solutions have been used
Sensitive to smoke
May avoid eating in cafeteria or be faddy about foods which have a strong smell
Smells everything
Taste and Smell: Hyposensitive
Never comments on strong smells
Never notices food being cooked (like cookies or popcorn)
Overfills mouth
May choose or avoid foods because of texture rather than smell or taste
Doesn't know how to sniff well or at all
Does not derive pleasure from eating, or may hate eating and not particular to sweets
Chews on things like pens
Does not notice strong smells like something burning
May eat indiscriminately, like at risk of eating substances labeled "Keep out of reach of children"
Extremely picky eater
Miscellaneous
Poor at catching a ball
Difficulty manipulating zippers, buttons, or small objects
Craves excessive movements (amusement park rides)
Tends to lean on things
Excessively emotional
Difficulty reading body language
Suicidal tendencies
Lays head on table or desk when doing work
Obsessive compulsive tendencies
Fatigues easily
Should be Empty:

Behavioral Evaluation Record

Psychological/Emotional Behaviors

Academic Skills

Attention/Hyperactivity Behaviors

Vestibular System

Visual system

Auditory System

Proprioception

Tactile: Hypo-tactile

Tactile: Hyper-tactile

Taste and smell: Hypersensitive

Taste and Smell: Hyposensitive

Miscellaneous