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Clinical Assessment Tool

This document contains a clinical observation form to assess and grade various motor skills and reflexes in children. It includes sections to evaluate eye movements, hand dominance, diadochokinesis, protective reactions, equilibrium reactions, reflexes, and postural control. Scores of 1 to 3 are circled to indicate performance from deficient to normal. Comments can be written to note differences between right and left sides.

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dominiquejonker05
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1K views5 pages

Clinical Assessment Tool

This document contains a clinical observation form to assess and grade various motor skills and reflexes in children. It includes sections to evaluate eye movements, hand dominance, diadochokinesis, protective reactions, equilibrium reactions, reflexes, and postural control. Scores of 1 to 3 are circled to indicate performance from deficient to normal. Comments can be written to note differences between right and left sides.

Uploaded by

dominiquejonker05
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CLINICAL OBSERVATIONS (ADAPTED FROM AYRES, J)

Name of child: Date:

Therapist: Age:

Key: 3 - normal function; 2 - slightly deficient; 1 - definitely deficient

TO SCORE

Circle the appropriate number and fill in observations and right/left differences in
comment column where applicable. For scoring criteria and interpretation, see manual.

TEST GRADE COMMENTS

Muscle tone

Eye preference Eye Hand used Comments

Subject’s eye through ring of examiner’s R/L R/L


finger

Subject’s eye through telescope R/L R/L

Subject’s eye through hole in paper R/L R/L

Independent eye closure

L eye Yes/No

R eye Yes/No

Eye movements Grade Comments

In general 3 2 1

Across midline 3 2 1

Convergence 3 2 1

Quick localization 3 2 1
Slow movements 3 2 1

Secs

Diadochokinetic

Right (___ times) 3 2 1

Left (____ times) 3 2 1

Both (___ times) 3 2 1

Thumb-Finger touching

Right 3 2 1

Left 3 2 1

Both 3 2 1

Tongue-Lip movements

Upper lip 3 2 1

Lower lip 3 2 1

Sides 3 2 1

Combined 3 2 1

Co-contraction

Upper limbs 3 2 1

Neck 3 2 1
Gravitational security 3 2 1

TEST GRADE COMMENTS

Equilibrium reactions

Prone 3 2 1

Quadruped 3 2 1

Long sitting 3 2 1

Upright kneeling 3 2 1

Protective extension

Arms 3 2 1

Legs 3 2 1

Prone extension

Secs 3 2 1

Asymmetrical tonic neck reflex

Quad position
Degs 3 2 1
R L

Reflex inhibiting position 3 2 1


Symmetrical tonic neck reflex

Degs
R L 3 2 1

Supine flexion posture

Secs 3 2 1

Schilder’s arm extension test

Involuntary movements 3 2 1

Postural changes 3 2 1

Trunk rotation 3 2 1

Hyperactivity 3 2 1

Tactile defensiveness 3 2 1

Postural background movements 3 2 1

Hopping 3 2 1

Jumping 3 2 1

Skipping 3 2 1

Throwing 3 2 1

Catching 3 2 1

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