<p> OCCUPATIONAL THERAPY PROGRESS REPORT CHECKLIST TURNING FIVE</p><p>Date: ______</p><p>Student’s Name: ______OSIS#: ______Date of Birth: ______</p><p>Functional Range of Motion: describe areas of limitations and the impact on the child’s ability to perform functional activities i.e. eating, dressing, sitting, play skills.</p><p>Fine Motor Skills: Yes No Comments Points with index finger Reaches for objects Turns pages Uses crayons, pencil Snips with scissors/thumbs up Cuts along line Cuts out circle Cuts out square Holds/turns paper while cutting Able to copy step pattern using 6 blocks Carries lunchbox</p><p>Describe Grasp:</p><p>Pre-Writing: Yes No Comments Traces a vertical line Traces a horizontal line Traces a circle Traces a square Imitates a vertical line Imitates a horizontal line Imitates a circle Imitates a square Copies a vertical line Copies a horizontal line Copies a circle Copies a square Draws a vertical line Draws a horizontal line Draws a circle Draws a cross</p><p>Student’s Name: ______1 OCCUPATIONAL THERAPY PROGRESS REPORT CHECKLIST TURNING FIVE</p><p>Draws a square Marks, scribbles Connects the dots Colors within the lines Serial opposition –right Serial opposition- left Grasp pattern- circle Power Hook</p><p>Spherical Cylindrical Skilled use of dominant hand Pinch patterns Lateral Pad to Pat</p><p>Tip to Tip 3 jaw chuck</p><p>Communication: Yes No Comments Verbal Uses gestures Makes eye contact Initiates interaction</p><p>Orientation and Memory: Yes No Comments Recognizes self in mirror States name Recognizes body parts Remembers routines Recalls personal events Remembers auditory information Remembers visual information</p><p>Play: Yes No Comments Plays alone Plays with others Exhibits imaginary play Exhibits symbolic play Uses toys purposefully Can occupy self</p><p>Life Skills: Yes No Comments Puts on jacket</p><p>Student’s Name: ______2 OCCUPATIONAL THERAPY PROGRESS REPORT CHECKLIST TURNING FIVE</p><p>Takes off jacket Puts on sweater Takes off sweater Fastens snaps Attempts to zipper Attempts buttons Hangs up coat Drinks from a cup Indicates need to use bathroom in a timely manner Moves from classroom to bathroom and bathroom to classroom Enters and exits stall Locks and unlocks door Manages clothing Obtains toilet paper Uses toilet paper Washes hands</p><p>Self Regulation and Attention: Yes No Comments Notices the environment Attends during instruction Follows simple directions Works independently Shifts attention as needed Stays alert Fidgets excessively Waits for turn Follows class rules Adapts to change Transitions easily Responds to familiar people Form attachments Participates in conversation Cooperates in a group Develops friendships Copes with frustration</p><p>Wheelchair Mobility:</p><p>Manual or Electric</p><p>Student’s Name: ______3 OCCUPATIONAL THERAPY PROGRESS REPORT CHECKLIST TURNING FIVE</p><p>Yes No Comments Self propel Able to navigate school Ascend ramp Descend ramp Locks brakes Unlocks brakes</p><p>Sensation: Yes No Comments Accepts being touched Assists in personal grooming Touches others appropriately Respects space of others Comfortable using class materials Body awareness Moves without bumping into objects/people Uses a heel-toe gait pattern Imitates a novel movement pattern Incorporates visual, verbal and tactile information Stays alert during class Regulates reaction to stimuli Inhibits excessive movement Attends to instruction Adapts to unpredictable sounds Orients to auditory stimuli Makes eye contact with people Looks at objects Attends to relevant visual info Matches/Sorts colors Matches/Sorts shapes Identifies up, down Identifies under, over Identifies top, bottom</p><p>Student’s Name: ______4 OCCUPATIONAL THERAPY PROGRESS REPORT CHECKLIST TURNING FIVE</p><p>SUMMARY and RECOMMENDATIONS</p><p>A. Summary of Present Level of Function (summarize the student’s school-based fine motor function, outlining both strengths and weaknesses and how this may impact their ability to participate in the school environment)</p><p>B. School-Based Occupational Therapy is □ recommended Frequency Duration Group</p><p>Explain how School-Based Occupational Therapy will benefit the student’s function and performance in his/her educational program (Please include suggested goals/objectives):</p><p>□ not recommended because</p><p>□ the student’s needs can be met by the primary education program. □ the student’s current function is at an appropriate level given the nature of his/her disability. □ the student’s physical limitations or deficits do not interfere with his/her participation in the school environment. □ the student’s deficits cannot be addressed by school-based occupational therapy. □ others: ______</p><p>C. Other Suggestions</p><p>Student’s Name: ______5 OCCUPATIONAL THERAPY PROGRESS REPORT CHECKLIST TURNING FIVE Therapist’s Name: (Print)______Preschool:______</p><p>Student’s Name: ______6</p>