Pediatric Functional Assessment Tool

PEDIATRIC FUNCTIONAL ASSESSMENT TOOLDeveloped by Mary Jones, OTR/L – Sensational Kids, LLCASSESSMENT COMPLETED BY: RELATION TO CHILD:DATE COMPLETED:CHILD’S DATE OF BIRTH:ADDRESS:CHILD’S MEDICAL HISTORY: (birth to present) ______FATIGUE:1. How much does fatigue interfere with daily or school functioning? (check one below)Fatigue is Fatigue mildly Fatigue moderately Fatigue severely not a problem limits activities limits activities limits activities2. Please indicate number of naps patient takes daily:______3. Please indicate typical duration of naps:______4. Please indicate typical number of hours of sleep patient gets each night:______5. Does patient takes medication to help sleep? YES NO 6. Does patient take medication(s) during the day that may cause drowsiness? YES NO NAME OF MEDICATION(S):______COGNITIVE-COMMUNICATIVE ABILITIES:Please check the appropriate boxes below.ABILITY No Problem Mild Problem Moderate Severe Problem ProblemConcentrating for short periods of timeConcentrating for extended periods of time Concentrating when there is noise or other distractionsConcentrating on more than one thing at a timeABILITY No Problem Mild Problem Moderate Severe Problem ProblemMental endurance to get through the day at home or schoolFeeling overwhelmed or anxious in large crowds or noisy environments – avoid them or leave earlyFeeling overwhelmed or anxious in large or visually stimulating places (i.e., department store, mall) Paying attention to what time it is Paying attention to what is happening in surrounding environmentInitiating to participate in daily activities or interactions Putting tasks in order of priority – anticipating own needsFollowing through with tasks to completionBeing flexible to change plans if other priorities ariseBeing able to transition between activitiesGenerating solutions to problems ABILITY No Problem Mild Problem Moderate Severe Problem ProblemAnticipating positive & negative consequences of actionsConsidering needs of self and/or others when making decisionsAvoiding activities that are unsafe or restricted by parents/caregiversRemembering daily scheduleRemembering play time & interactions Remembering day to day eventsRecalling familiar namesRemembering facesSelf-organizing items needed for schoolOrganizes own clothesEager to readComprehending when reading Comprehending when reading chapters of a book Staying focused while reading a book or magazineRemembering what was readUnderstanding speech when someone is talking ABILITY No Problem Mild Problem Moderate Severe Problem ProblemUnderstanding speech when on the phoneUnderstanding conversation in a group of peopleEnunciating speech soundsThinking of words to express selfOrganizing thoughts to express ideas clearly and conciselyAccessing more complex vocabulary to express self Spelling/writing for homework needsBEHAVIOR AND SOCIAL INTERACTION:Please check the appropriate boxes below.BEHAVIORS, FEELINGS, AND No Problem Mild Problem Moderate Severe INTERACTIONS Problem ProblemGets frustrated easilyYelling at othersHitting othersHitting walls or objectsActing dangerouslyOverreacting to situationsBEHAVIORS, FEELINGS, AND No Problem Mild Problem Moderate Severe INTERACTIONS Problem ProblemCrying more than usual – particularly at times when stressed or overwhelmedLaughing more than usual or at the wrong time – particularly at times when stressed or overwhelmedWithdrawing from others when overwhelmedAppropriate use of personal spaceWithdraws from activities that are perceived to be too hardTolerates loud or unexpected noise stimulus Initiating to talk to others – to start conversationsTalking too much – rambles on….Jumping from one topic to another while talking – forgetting the original topic at timesInterrupting others when they are in the middle of speakingForgetting to make eye contact when talking to others or being talked toTolerates light/deep touchTolerates warm/cold temperatures Causes harm to selfCauses harm to othersDamages propertyACTIVITIES OF DAILY LIVING:Please check the appropriate boxes below.ACTIVITY No Problem Mild Problem Moderate Severe Problem ProblemGetting in & out of tub/showerBathing thoroughlyGrooming thoroughlyDressing upper bodyDressing lower body Paying attention to the left side of body/spacePaying attention to the right side of body/spaceGetting on & off the toiletInitiating to use the toiletBladder continence Bowel continenceBrushing teethCombing/brushing hairOpening food containersPouring self a drinkACTIVITY No Problem Mild Problem Moderate Severe Problem ProblemHelping with household chores as directedInitiate play activities with sibling or peer groupAble to cut foodsAble to lay the tableAble to manipulate straw into juice pouch/boxWalking on even surfacesWalking on grass, sand, or other uneven surfaceWalking up and down stairsMaintaining balance to walk within the homeKeeps up with peers in physical activities Physical endurance to get around the communityRunning/jogging/sportsUsing feeding utensilsGetting hand to mouth for feedingPreparing a snackLimited repertoire of foods (please list on back of sheet)Avoids certain textures (please list on back of sheet)ACTIVITY No Problem Mild Problem Moderate Severe Problem ProblemTolerates loose clothingTolerates form fitting clothing (i.e. socks)Prefers snacking to sit down mealsTolerates hot/cold foodsMay choke/gag during eatingMakes a mess when eatingAvoids mess when eatingAble to clear spoon bowl (clean spoon) with lips when eating soft foods i.e.puddingAble to sit still at the table during mealtimesTakes 20+ minutes to complete a mealTakes less than 10 mins to complete a meal May become upset at mealtimes if routine changesMay choke during drinkingFrequent runny nosePresents with allergies?Often chews on non-food items (i.e. pencil tops/shirt collars)Responds to verbal disciplineACTIVITY No Problem Mild Problem Moderate Severe Problem ProblemResponds to time outResponds to cause and effect (binary choice)ACADEMIC SKILLS:Please check the appropriate boxes below. ACADEMIC SKILL No Problem Mild Problem Moderate Severe Problem ProblemUnderstanding classes Understanding teacher instructions for assignmentsPaying attention in classConcentrating when reading Frequently loses place when readingSkips words when readingSounding out words when readingIdentifying meaning of words when readingRemembering content of what is readUnderstanding more abstract language when readingKeeping homework and class notes organizedACADEMIC SKILL No Problem Mild Problem Moderate Severe Problem ProblemRemembering to complete homework assignments Remembering to turn in homework and projects Self-initiating to complete homework, projects, or prepare for tests/quizzesLearning and retaining what is learned to take tests/quizzesMotivation toward schoolDoes your child have a history of:Dyslexia? ___ YES ___ NONonverbal Learning Disorder? ___ YES ___ NOSpecified Learning Disorder (SLD)? ___ YES ___ NOLearning Delay? ___ YES ___ NOConcussion During Sports? ___ YES ___ NO Prematurity? ___ YES ___ NO Did your child reach developmental milestones on time for speech, language, and motor skills? ___ YES ___ NOGive examples: i.e. walked at: ______, crawled: ______etc. List current classes and grades for each:Class: Grade: Class: Grade:Class: Grade: Class: Grade:Class: Grade: Class: Grade:List extracurricular activities (sports, clubs, playtime, etc):Thank you for taking the time to complete this assessment. 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Pediatric Functional Assessment Tool

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