governed in ⚙️ Clinic settings · fields ▾
Patient
✎ editFamily & Contacts
✎ editWho cares for this child and how to reach them. These details stay in the record — they are never part of any generated content.
⚖️ Custody & consent notes (who may consent / receive records)
Care Team
✎ editReferral & Insurance
✎ editHistory
✎ edit📌 Memos
Administrative notes — scheduling, phone calls, anything not clinical. Stamped with the author and time; never printed, never part of any generated content. A memo covering a date range explains those weeks on the Treatment page's attendance strip.
No memos yet.
📎 Documents
IEPs, outside evaluations, referrals, insurance documents — filed into this patient's own Documents/ folder in the clinic's storage. Nothing here ever leaves that storage.
No documents attached yet.
📋 Patient Intake Summary
👁 Observations & Comments
🧠 Assessment: Behavior
iCheck ✓ if behavior is Age-Appropriate.Leave unchecked if a concern exists.
Add specific observations in Comments.
Check "Appropriate" if the behavior is within typical range. Leave unchecked and add comments to describe concerns.
| Behavior Domain | Appropriate | Comments |
|---|---|---|
| Activity Level | ||
| Social Skills | ||
| Visual Attention | ||
| Behaviors | ||
| Direction Following | ||
| Emotional Regulation |
🔬 Assessment: Clinical Observations
| Domain | Comments |
|---|---|
| Vestibular | |
| Balance | |
| Bilateral Coordination | |
| Visual Skills | |
| Tone / Posture |
✋ Assessment: Fine Motor Observation
| Domain | Age Appropriate | Delayed | Comments |
|---|---|---|---|
Handwriting Letter formation, legibility, sizing, spacing, and writing speed/endurance | |||
Manipulative Skills In-hand manipulation, pinch/grasp patterns, tool use, and object control | |||
Scissor Skills Asymmetrical bilateral coordination (cutting hand vs. stabilizing/rotating hand), visual-motor integration, motor planning to sequence the cutting steps, and hand/finger dissociation (isolating ring/pinky from the cutting fingers) | |||
Diadochokinesia Rapid alternating movements (e.g. forearm pronation/supination) — assesses motor coordination and timing | |||
Finger Opposition — With Vision Sequential thumb-to-finger opposition performed with visual feedback — assesses fine motor sequencing and dexterity | |||
Finger Opposition — Vision Occluded Same sequential thumb-to-finger opposition task performed without visual feedback (eyes closed/occluded) — assesses proprioceptive awareness and motor planning without visual cues |
📊 Standardized Test Scores
🖼️ Clinical Media — Handwriting & Drawing Samples
Upload handwriting samples, drawings, cutting tasks, or other clinical media. Images are embedded in exported reports.
👁 Assessment: Visual Motor Skills
iNC = No Concern (age-appropriate)Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Visual Motor Skills Copying shapes, designs, and forms; eye-hand coordination during pencil tasks. |
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Visual Tracking (w/o moving head) Ability to smoothly follow a moving object with the eyes. |
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Saccades Quick eye movements that shift focus from one point to another. |
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Convergence Ability of both eyes to turn inward and focus on something up close. |
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Visual Tracking for Social Communication & Joint Attention Demonstrates social referencing by tracking finger trajectory and reading facial expressions to guide motor and social interaction. |
📊 Standardized Test Scores
💪 Assessment: Hand Strength
| Hand | Grip Strength i | SD | Three Jaw Chuck / Three Point Pinch i | SD manual | Key Pinch i | SD manual |
|---|---|---|---|---|---|---|
| Right | Bina | |||||
| Left | Bina |
⚡ Assessment: Primitive Reflexes
iIntegrated: Reflex inhibited (normal)Moderately Retained: Partial presence, mild impact
Severely Retained: Strong presence, significant functional impact
| Primitive Reflex | Concern | No Concern | Not Tested | Comments |
|---|
🌀 Clinical Observations: Sensory Motor
iNC = No Concern (typical) | Seek = SeekingSensitive = Over-responsive | Reg = Under-responsive
Avoid = Active avoidance of input
Check all that apply for each sensory domain. Multiple columns may be checked per row.
| Domain | No Concern | Seeker | Sensitivity | Registration | Avoider | Comments |
|---|
Post-Rotary Nystagmus (PRN)
| Observation | No Concern | Concern | Comments |
|---|---|---|---|
Post-Rotary Nystagmus (PRN) Involuntary rhythmic eye movement following spinning; reflects vestibular processing. Absent or prolonged PRN may indicate vestibular dysfunction. |
📊 Standardized Test Scores
🏋️ Assessment: Strength
| Domain | Comments |
|---|---|
|
Supine Flexion
Core flexor strength; child lifts head, trunk, and legs while supine — hold is timed.
Norms: Ages 5–6: ~20 sec | Ages 7–8: ~30 sec | Ages 9–10: ~40 sec | Ages 11–12: ~50 sec |
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Prone Extension
Extensor muscle strength; child lifts head, chest, and legs off the surface while prone — hold is timed.
Norms: Ages 5–6: ~8 sec | Ages 7–8: ~20 sec | Ages 9–10: ~30 sec | Ages 11–12: ~40 sec |
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Upper Extremity
Shoulder, arm, and hand musculature; assessed via pushing, pulling, weight-bearing, and manipulation tasks.
Norms: Should sustain wheelbarrow walk, complete modified push-ups, and manage monkey bars for age (typically 6+) |
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Lower Extremity
Hip, thigh, and leg strength; assessed via jumping, squatting, stair climbing, and balance tasks.
Norms (standing broad jump): Age 5: ~3–4 ft | Age 7: ~4–5 ft | Age 9: ~5–6 ft | Age 11: ~6–7 ft |
🦸 Superpowers
iHighlight the child's strengths, talents, and what makes them unique — a strengths-based counterpart to the deficit-focused sections. Included in the exported report.⚡ Functional Impact Statements
iDescribe how assessment findings affect the child's daily functioning across key life domains. These statements are included in the exported report and help families and educators understand the real-world significance of the evaluation.Describe how the child's deficits impact performance in each area. Leave blank if not applicable. ✨ Draft with AI writes each domain from the findings, parent concerns and goals already on file — grounded only, a domain nothing supports stays empty — and you tick what to keep.
📝 Clinical Summary
📅 Plan of Care
🎯 Goals
📐 What makes a goal measurable?
A measurable goal names something you can see and something you can count. Everything else is good practice, not a requirement. A worked example:
- ✓ Observable skill (required) — an action you could watch happen: “write his name,” “don his jacket” — not “improve” or “increase.”
- ✓ Criterion (required) — how often or how well: “in 4 of 5 trials,” “with 80% accuracy,” “for 30 seconds.” Writing one auto-fills the objective’s Target %.
- Condition (good practice) — the setup (“Given a visual model…”). Not required for measurability — it makes your measurements comparable week to week.
- Assist level (good practice) — how much help (“independently,” “with moderate cues”). Progress is often the help fading.
- Timeframe (long-term goals) — the horizon (“Within 12 weeks…”).
If the verb is “improve,” “increase,” or “understand,” there’s nothing to count yet — say what you’d see instead. The GOAL ANATOMY chips under each goal show what’s detected; they inform, never block.
🧩 Recommended Therapeutic Interventions
🤝 Referrals / Other Professionals Needed
📚 Recommended Reading
📊 Score Profile — Quadrant
Click ♦ to mark the client's score placement. Ranges are pre-filled from the scoring guide.
| Much less than others |
Less than others |
Just like the majority of others |
More than others |
Much more than others |
Notes | |
|---|---|---|---|---|---|---|
| Quadrant | ||||||
| Seeking / Seeker | 0—6 |
7—19 |
20—47 |
48—60 |
61—95 |
|
| Avoiding / Avoider | 0—7 |
8—20 |
21—46 |
47—59 |
60—100 |
|
| Sensitivity / Sensor | 0—6 |
7—17 |
18—42 |
43—53 |
54—95 |
|
| Registration / Bystander | 0—6 |
7—18 |
19—43 |
44—55 |
56—110 |
|
📊 Score Profile — Sensory & Behavioral Sections
Click ♦ to mark score placement. ** indicates N/A or insufficient items for this column.
| Much less than others |
Less than others |
Just like the majority of others |
More than others |
Much more than others |
Notes | |
|---|---|---|---|---|---|---|
| Sensory Section | ||||||
| AUDITORY Processing | 0—2 |
3—9 |
10—24 |
25—31 |
32—40 |
|
| VISUAL Processing | 0—4 |
5—8 |
9—17 |
18—21 |
22—30 |
|
| TOUCH Processing | 0 |
1—7 |
8—21 |
22—28 |
29—55 |
|
| MOVEMENT Processing | 0—1 |
2—6 |
7—18 |
19—24 |
25—40 |
|
| BODY POSITION Processing | 0 |
1—4 |
5—15 |
16—19 |
20—40 |
|
| ORAL SENSORY Processing | ** |
0—7 |
8—24 |
25—32 |
33—50 |
|
| Behavioral Section | ||||||
| CONDUCT associated with sensory processing | 0—1 |
2—8 |
9—22 |
23—29 |
30—45 |
|
| SOCIAL EMOTIONAL responses associated with sensory processing | 0—2 |
3—12 |
13—31 |
32—41 |
42—70 |
|
| ATTENTIONAL responses associated with sensory processing | 0 |
1—8 |
9—24 |
25—31 |
32—50 |
|
📋 SP2 Reports
One card per other rater's SP2 report (e.g. the School Companion when the chart above is the parent's), each named by who completed it. Import fills scores automatically; Add Blank opens a form to enter scores manually. Bina's AI reads the chart and every card, each by its rater.
🧑 Adolescent/Adult Sensory Profile (AASP)
For an adolescent or adult client assessed with Winnie Dunn's AASP. Add one card per report (Self-Report or Caregiver/Observer). Enter the 4 quadrant scores (raw out of 75) and, optionally, the 6 sensory-processing section scores. Feeds the Summary Narrative below.
🏃 Assessment: Gross Motor
| Domain | Comments |
|---|---|
|
Bilateral Coordination
Coordinated use of both sides of the body simultaneously or in alternating sequence.
Clinical examples: jumping jacks, windmills, skipping, catching with two hands, reciprocal arm/leg movements |
|
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Postural Control & Core Stability
Ability to maintain upright alignment and stabilize the trunk against gravity during static and dynamic tasks.
Clinical examples: sitting unsupported, transitioning from sit to stand, prone extension, supine flexion Note: Supine Flexion / Prone Extension hold-time norms are recorded on the Strength page — use this row for broader postural/core observations. |
|
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Upper Limb Coordination
Coordinated use of the arms and hands for gross motor tasks requiring timing and accuracy.
Clinical examples: catching, throwing, dribbling one- or two-handed, overhead reach patterns Norms (general developmental milestones): Age 3–4: catches with both hands against chest; hits a 2 ft target from 5 ft with an underhand toss | Age 5–6: trunk rotation emerges in overhand throw | Age 6: bounces and catches a ball with one hand | Age 7: mature overhand throwing pattern with weight transfer |
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Static Balance
Ability to maintain a stable position without movement.
Clinical examples: standing on one foot (eyes open and eyes closed), tandem stance, standing on an unstable surface Norms (single-leg stance, eyes open; Condon & Cremin, 2014): Age 3–4: ~5 sec | Age 4–5: ~10 sec | Age 6+: generally >8–10 sec, continuing to improve through ages 7–8. Eyes-closed duration is typically shorter — treat as a relative comparison, not an absolute cutoff. |
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Dynamic Balance
Ability to maintain postural control during movement.
Clinical examples: walking on a balance beam, navigating obstacle courses, donning/doffing through play Norms (4-inch-wide balance beam): Age 3–4: walks alone but may step off or need occasional support | Age 4.5–5.5: walks several feet without stepping off |
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Agility & Motor Planning
Ability to change direction, sequence movements, and execute motor plans efficiently.
Clinical examples: imitation of movement sequences, moving in and out of a dynamic swing |
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Functional Locomotion
Functional movement through space using developmentally appropriate patterns.
Clinical examples: running, galloping, skipping, heel-to-toe walking Norms (typical age of acquisition): Age 4: hops on one foot, walks backward in tandem | Age 5: gallops and skips with alternating feet | Ages 5–7: heel-to-toe (tandem) walking becomes consistent |
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Muscle Tone & Endurance
Resting tension in muscles and ability to sustain gross motor effort over time.
Clinical examples: sustained prone extension, endurance during physical tasks, resistance to fatigue |
Norms shown above are general pediatric developmental milestones drawn from published clinical literature (not a specific standardized test) — use as a reference point alongside clinical judgment and any standardized tests administered.
📊 Standardized Test Scores
🧠 Clinical Observations: Executive Functioning
What you observed in session for each area — if a parent or teacher reported it, say so in the comment. Untouched rows are left out of the report; add a BRIEF2 below when one was completed.
| Domain | No Concern | Concern | Comments |
|---|---|---|---|
Sustained attention Stays with a task; drifts; needs redirection. |
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Inhibition / impulse control Waits for instructions; blurts; grabs materials. |
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Shifting / flexibility Moves between activities; gets stuck; tolerates a change of plan. |
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Emotional control Recovers from frustration; reactions match the situation. |
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Initiation Starts on cue vs. needs repeated prompting. |
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Working memory Follows two- and three-step directions; loses the thread. |
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Planning & organization Sequences a multi-step task; anticipates what is needed. |
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Time management & pacing Paces a task to the time given; responds to a two-minute warning; finishes without a rush at the end. |
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Task monitoring / self-check Notices and fixes errors; checks work. |
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Organization of materials Keeps a workspace; finds and puts away tools. |
Domain descriptions are the tool’s own plain-language definitions of what each area looks like in a session — not the wording of any published instrument.
🧠 The BRIEF 2 (Behavior Rating Inventory of Executive Function) optional
Add one card per BRIEF2 report (Parent Form, Teacher Form, Self-Report Form). Import extracts the score summary automatically from a PDF/DOCX report; Add Blank opens a form to enter scores manually. Only raw/T/percentile scores and the validity classification are captured — the publisher's interpretive paragraphs and intervention suggestions are never imported. Use Clinician Notes for your own observations.
ℹ️ About BRIEF2 Scores — T-Scores & Percentiles Explained
The BRIEF (Behavior Rating Inventory of Executive Function) is a standardized questionnaire used to evaluate executive functioning. Scores are based on reports from parents, teachers, or self-reports.
Higher raw scores reflect more frequent problem behaviors. These raw totals are converted into T-scores and percentiles for interpretation.
T-Scores Explained
A T-score is a standardized score that allows professionals to compare an individual's executive functioning against a normative group of same-aged peers. [1]
T-score benchmarks typically signify the following: [2][3][4]
- T < 60: Within normal limits (Average)
- T 60–64: Mildly elevated (may indicate subtle, subclinical difficulties)
- T 65–69: Potentially clinically elevated (considered slightly atypical from the norm)
- T ≥ 70: Clinically significant / Highly elevated (indicates substantial executive dysfunction that may require intervention)
Percentiles Explained
A percentile tells you what percentage of the standardization sample scored at or below the individual's score. It shows exactly where someone stands compared to peers.
- 50th percentile: Perfectly average — the individual scored exactly in the middle of the peer group.
- 84th percentile: Corresponds to a T-score of 60 — the individual scored equal to or worse than 84% of peers (and better than 16%).
- 93rd percentile: Corresponds to a T-score of 65 — the individual scored equal to or worse than 93% of peers.
Sources: [1] ACER — BRIEF Interpretive Sample · [2] PAR — BRIEF2 Self-Report Sample · [3] ACER — BRIEF2 Parent Sample · [4] ScienceDirect — BRIEF Topic Overview
📊 Standardized Test Scores
🗂️ Background Information
⚠️ Precautions
🧿 Assessment: Visual Perception
iVisual perception is the brain's ability to interpret and make sense of visual stimuli (colors, shapes) in the environment.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Visual Spatial Awareness Ability to perceive objects in relation to each other and to oneself. |
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Sequential Memory Ability to remember and recall a sequence of visual inputs in the correct order. |
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Visual Discrimination Ability to differentiate between objects and shapes. |
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Form Constancy Ability to see a form or shape and identify it among other forms, regardless of changes in orientation or size. |
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Visual Memory Ability to store visual details in short-term memory. |
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Visual Closure Ability to fill in an incomplete shape or form with missing details. |
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Visual Figure-Ground Ability to perceive a form and find it among many other items. |
📊 Standardized Test Scores
🌐 Language & Hearing Background
iThe language history and hearing status the whole evaluation is read against: home languages, exposure, the language of assessment, interpreter use, hearing screening results, ear infections/tubes, and early milestones. Fill it before the assessment areas — an interpreter or a failed hearing screen changes how every score is read.Language exposure
Hearing
Speech-language history
👂 Assessment: Receptive Language
iWhat the child understands: directions, vocabulary, concepts, questions, sentence structure, and connected discourse — from observation, play, and testing.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Following directions One-, two-, and multi-step directions; with and without gesture or repetition; length and complexity tolerated. |
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Vocabulary comprehension Understanding of nouns, verbs, attributes, and category words for age; identifies pictures/objects named. |
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Basic concepts Spatial (in/under/behind), temporal (before/after), quantity (more/all), and quality (same/different) concepts. |
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Understanding questions Responds appropriately to yes/no and wh- questions (what/where/who → when/why/how) for age. |
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Sentence & grammar comprehension Understands longer and complex sentences: negatives, passives, embedded clauses, pronoun reference. |
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Story & discourse comprehension Main idea, sequence, and inference from a short story or conversation; recalls details. |
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Attention & listening for language Sustains attention to spoken language; benefits from repetition, slowed rate, or visual support. |
📊 Standardized Test Scores
🗣️ Assessment: Expressive Language
iWhat the child produces: vocabulary, utterance length, grammar, sentence structure, narrative, and functions of language — from a language sample and testing.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Vocabulary use Variety and specificity of words; word-finding (pauses, fillers, circumlocution, overuse of "thing"). |
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Utterance length Typical and longest utterances (words / morphemes) relative to age expectations. |
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Grammar & morphology Verb tense, plurals, possessives, pronouns, articles, auxiliaries — accuracy and omissions. |
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Sentence structure Simple → compound → complex sentences; use of conjunctions and clauses; word order. |
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Narrative & discourse Retells and generates stories: sequence, story-grammar elements, cohesion, referencing. |
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Communicative functions Requests, comments, protests, answers, asks questions, describes, explains — range for age. |
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Language sample notes Context, sample size, elicitation (play/picture/conversation), and what it showed. |
📊 Standardized Test Scores
🔤 Assessment: Articulation & Phonology
iSpeech-sound production: the sound inventory, error patterns, stimulability, consistency, and how understandable the child is to familiar and unfamiliar listeners.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Sound inventory & errors Sounds produced correctly and in error, by word position; developmental vs. non-developmental errors. |
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Phonological patterns Processes such as fronting, stopping, gliding, cluster reduction, final-consonant deletion, weak-syllable deletion — and whether age-appropriate. |
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Stimulability Sounds in error the child can produce with a model or cue (sound / syllable / word level). |
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Intelligibility Percent understood by a familiar and an unfamiliar listener; single words vs. connected speech. |
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Connected-speech accuracy Whether accuracy holds from single words into phrases and conversation. |
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Consistency of errors Same word said the same way? Inconsistent errors, groping, or vowel errors that warrant a motor-speech look. |
📊 Standardized Test Scores
🤝 Assessment: Social / Pragmatic Communication
iHow the child uses communication with people: joint attention, nonverbal communication, turn-taking, topic, perspective, play, and repair — observed across play and conversation.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Joint attention & shared engagement Follows a point/gaze, shows and gives to share, sustains back-and-forth engagement. |
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Nonverbal communication Eye gaze, gesture, facial expression, and body orientation used to communicate and to read others. |
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Turn-taking & topic Takes conversational turns, maintains and shifts topic appropriately, adds related information. |
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Initiating & responding Starts interactions and responds to bids from adults and peers; greetings; requests for help. |
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Perspective-taking Considers the listener: adjusts message, recognises others’ feelings/knowledge, understands non-literal language for age. |
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Play skills Functional, symbolic/pretend, and cooperative play; flexibility and imagination. |
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Repair & register Notices breakdowns and repairs (repeats, rephrases); adjusts style to setting and partner. |
📊 Standardized Test Scores
👄 Assessment: Oral-Mechanism & Motor Speech
iStructure and function of the speech mechanism and the motor-planning features of speech: symmetry, strength/range, diadochokinesis, groping, prosody.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Structure Lips, tongue, hard/soft palate, dentition/occlusion, jaw symmetry — within normal limits or notable. |
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Function — strength & range Lip closure/rounding/retraction, tongue elevation/lateralization/protrusion, jaw stability and grading. |
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Diadochokinesis Rate and accuracy of /pʌ/, /tʌ/, /kʌ/ and /pʌtʌkʌ/; sequencing breakdowns. |
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Motor-planning features Groping, inconsistent errors on repeated words, vowel distortions, difficulty with longer/complex words, syllable-stress errors. |
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Prosody & rate Stress, intonation, rhythm and rate of connected speech. |
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Drooling & oral awareness Saliva management, oral sensory responses, awareness of the articulators. |
📊 Standardized Test Scores
🎙️ Assessment: Voice & Resonance
iPerceptual assessment of vocal quality, pitch, loudness, resonance, breath support, and vocal habits.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Vocal quality Breathy, hoarse, rough, strained, or clear; consistency across the session. |
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Pitch Habitual pitch and range appropriate for age and sex; pitch breaks. |
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Loudness Habitual loudness and the ability to vary it; too soft/too loud for context. |
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Resonance Hypernasality, hyponasality, or cul-de-sac resonance; nasal emission; velopharyngeal concerns. |
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Vocal habits Yelling, throat clearing, coughing, hydration, reflux symptoms, and other vocally demanding behaviors reported. |
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Breath support & phrasing Breath groups, coordination of breathing and speech, running out of air. |
📊 Standardized Test Scores
〰️ Assessment: Fluency
iThe flow of speech: types and frequency of disfluency, secondary behaviors, awareness and attitudes, and impact across settings.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Types of disfluency Sound/syllable/word repetitions, prolongations, blocks; vs. typical disfluencies (interjections, revisions, phrase repetitions). |
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Frequency Percent syllables (or words) stuttered per sample; sample context and length. |
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Secondary behaviors Physical tension, eye blinks, facial/body movements, escape or avoidance behaviors. |
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Awareness & attitudes The child’s and family’s awareness, reactions, and feelings about talking. |
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Impact on participation Effect on classroom talk, peers, and family conversation; situations avoided. |
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Variability across contexts Differences by partner, setting, excitement/fatigue, and linguistic complexity. |
📊 Standardized Test Scores
🥄 Assessment: Feeding & Swallowing
iOral-motor skills for eating and drinking, textures accepted, signs of swallowing difficulty, mealtime behavior, and self-feeding — from parent report and observation. Add this area when feeding is part of the referral.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Oral-motor skills for feeding Chewing pattern, tongue lateralization, lip closure on spoon/cup, bolus management. |
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Textures & food range Textures accepted or refused; variety across food groups; transitions (purée → mashed → solids). |
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Signs of swallowing difficulty Coughing/choking with liquids or solids, wet vocal quality, gagging, prolonged meals, respiratory history. |
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Mealtime behavior & sensory factors Refusals, distress, sensory responses to textures/smells, family mealtime routines. |
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Growth & nutrition concerns (reported) Weight/growth concerns, supplements, medical follow-up in place. |
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Positioning & self-feeding Seating/support, utensil use, cup drinking, independence for age. |
📊 Standardized Test Scores
📖 Assessment: Literacy & Phonological Awareness
iThe sound-structure skills under reading and spelling, letter-sound knowledge, rapid naming, and — for readers — decoding, fluency, and written expression. Add this area for school-age referrals with reading concerns.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Rhyming & alliteration Recognises and produces rhymes; identifies words starting with the same sound. |
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Syllable & phoneme awareness Segmenting and blending syllables and sounds; deleting/substituting sounds for age. |
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Letter–sound knowledge Letter names and sounds; applying them to simple decoding. |
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Rapid naming Speed and accuracy naming familiar colours/objects/letters/digits. |
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Decoding & reading fluency Sounding out and sight-word reading; accuracy, rate, and prosody in connected text (if applicable). |
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Spelling & written expression Sound-spelling accuracy and organisation of written sentences/paragraphs (if applicable). |
📊 Standardized Test Scores
🔊 Assessment: Auditory Processing
iHow the child handles spoken input beyond hearing acuity: listening in noise, auditory memory, discrimination, and reliance on visual support. Add when listening concerns are reported; an audiology referral decides the diagnosis.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Listening in noise Attention and accuracy for spoken language with background noise or in groups. |
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Auditory memory Digit/word span, recall of directions and sentences. |
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Auditory discrimination Telling similar sounds/words apart in isolation and in context. |
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Reliance on visual support Difference in performance with vs. without visual cues, gesture, or written support. |
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Sound sensitivity Distress or avoidance with everyday sounds; covering ears (reported/observed). |
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Audiology referral Whether a full audiological / (C)APD evaluation is indicated and why. |
📊 Standardized Test Scores
🖼️ Assessment: AAC & Alternative Modalities
iThe child’s current communication modalities and the case for augmentative/alternative communication: access, symbol understanding, trials, partner training, and a system recommendation. Add when speech alone does not meet the child’s communication needs.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Current communication modalities Speech, vocalisations, gestures, signs, pictures/PECS, device — what works and where each breaks down. |
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Access & motor/vision considerations Direct selection, pointing accuracy, scanning, visual acuity/field, seating and positioning. |
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Symbol & representation understanding Objects → photos → line drawings → text; matching, choosing, and combining symbols. |
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Trials conducted Systems and vocabularies trialled, tasks, and the child’s response. |
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Communication-partner needs Modelling, prompting, and environmental supports the family/school will need. |
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System recommendation Recommended low-/high-tech system, vocabulary organisation, and next steps (funding, training). |
📊 Standardized Test Scores
🧠 Assessment: Cognitive-Communication
iThe thinking skills that carry communication: attention, memory for language, executive functions in conversation and tasks, reasoning, processing speed, and self-monitoring. Add for older children or where cognition is part of the picture.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Attention Sustained, selective, and divided attention during language tasks and conversation. |
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Memory for language Working memory (holding and using spoken information) and recall of what was said/learned. |
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Executive functions in communication Planning and organising what to say, flexibility, inhibition, sequencing multi-step tasks. |
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Problem-solving & reasoning Verbal reasoning, predicting, inferencing, and explaining solutions. |
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Processing speed Time needed to understand and respond; benefit from extra time. |
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Self-monitoring Awareness of errors and breakdowns; use of strategies. |
📊 Standardized Test Scores
📋 Assessment: Informant Reports & Checklists
iWhat parents, teachers, and questionnaires say — the picture across home, school, and community, and how consistent it is with what was observed. Add when checklists or teacher input are part of the evaluation.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Parent / caregiver report Concerns, priorities, and examples from home; how the child communicates with family. |
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Teacher / school report Classroom participation, following instructions, peer communication, supports in place. |
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Communication at home Everyday routines, siblings, languages, and what helps. |
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Communication at school & in the community Groups, unfamiliar adults, structured vs. unstructured settings. |
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Questionnaires & checklists administered Instrument, respondent, and result summary (bands only — no publisher text). |
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Consistency across informants Where reports agree, where they differ, and how that shapes the recommendations. |
📊 Standardized Test Scores
📅 Treatment
🩺 History & Systems Review
iThe medical, orthopedic and motor history the whole evaluation is read against, and the systems review that decides what is safe to test: diagnoses, surgeries, precautions, equipment in use, milestones, prior therapy, pain, and the classification level where one applies. Fill it before the assessment pages.Birth & medical history
Systems review
Motor history
Pain
Classification
🧍 Assessment: Posture & Alignment
iStatic alignment in standing and sitting, spinal curves, lower-limb and foot alignment, and how weight is carried — observed before anything is measured.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Standing alignment Head, shoulders, spine, pelvis, knees and feet viewed from the front, side and back; symmetry left to right. |
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Sitting posture Pelvic position (neutral, posterior tilt), trunk and head control, and the support needed to sit for work or play. |
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Spinal curves Scoliosis screen (forward-bend asymmetry, rib hump), kyphosis, lordosis; flexible or fixed. |
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Lower-limb alignment Femoral and tibial torsion, knee angle (varus / valgus), leg-length difference, foot progression angle. |
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Foot posture Arch height, hindfoot and forefoot position, weight-bearing vs non-weight-bearing; flexible or rigid flat foot. |
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Weight distribution & symmetry Weight shift to one side, preferred stance leg, asymmetric loading in standing and sitting. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
📐 Assessment: Range of Motion & Flexibility
iJoint range and muscle length by region, hypermobility, and what limits the end of range — measured in degrees where a goniometer was used, recorded as a comparison with the other side otherwise.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Upper-extremity range Shoulder, elbow, forearm and wrist range, active and passive; side-to-side comparison. |
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Lower-extremity range Hip (flexion, extension, abduction, rotation), knee and ankle range; side-to-side comparison. |
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Spine & neck range Cervical rotation and lateral flexion, trunk flexion, extension and rotation. |
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Hamstring & hip-flexor length Popliteal angle, straight-leg raise, Thomas test position; tightness that limits stride or sitting. |
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Ankle dorsiflexion & calf length Dorsiflexion with the knee flexed and extended; contribution of gastrocnemius vs soleus. |
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Hypermobility & laxity Beighton-type screen of joint hypermobility, ligamentous laxity, and any joint that gives way. |
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End-feel & pain with movement Soft, firm or hard end-feel; guarding, pain or apprehension at the end of range. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
💪 Assessment: Strength & Muscle Performance
iMuscle strength by region and its functional expression — manual muscle grades where the child can follow the test, functional tasks (squat, sit-to-stand, stairs, jumps) where they cannot.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Upper-extremity strength Shoulder, elbow and wrist strength; weight-bearing through the arms (propping, wheelbarrow, crawling). |
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Lower-extremity strength Hip, knee and ankle strength by manual grade or functional test; side-to-side comparison. |
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Trunk & core strength Bridging, sit-up, plank or prone-extension hold; trunk control in transitions. |
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Functional strength Squat, sit-to-stand without hands, stairs without a rail, heel and toe walking, step-up height. |
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Power Vertical jump, standing broad jump, hop distance; explosive movement for age. |
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Muscle endurance Repeated sit-to-stand, wall-sit hold, repeated heel raises; fatigue over repetitions. |
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Symmetry & compensations Right–left differences and the substitutions the child uses (momentum, hands, trunk lean). |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
⚡ Assessment: Tone, Reflexes & Neuromotor Status
iMuscle tone by limb and trunk, spasticity and clonus, deep-tendon and primitive reflexes, righting and protective reactions, involuntary movement, and sensation — scaled where a scale was used (Modified Ashworth, Tardieu), described otherwise.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Muscle tone Hypotonia or hypertonia by limb and trunk; resting posture; scale and grade where scored. |
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Spasticity & clonus Velocity-dependent resistance, catch angle, sustained or unsustained clonus; the muscle groups involved. |
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Deep-tendon reflexes Patellar, Achilles, biceps and triceps responses; symmetry. |
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Primitive reflexes ATNR, STNR, Moro, tonic labyrinthine, plantar and palmar grasp — integrated or persisting for age. |
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Righting, protective & equilibrium reactions Head and trunk righting, protective extension forward, sideways and backward; tilt responses. |
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Involuntary movement Dystonia, athetosis, tremor, ataxia; when it appears and what settles it. |
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Sensation & proprioception Light touch, position sense, response to pressure and movement input; areas of reduced or heightened response. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
🧒 Assessment: Gross-Motor Development
iWhere the child is on the gross-motor sequence and how the skills look: prone and supine skills, sitting, transitions, standing and walking, stairs, running and jumping, ball skills — from observation and testing.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Prone & supine skills Head lifting, propping on forearms and hands, reaching in prone, rolling both ways. |
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Sitting Attained and maintained; transitions into and out of sitting; floor sitting positions used (W-sit, ring, side). |
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Crawling & transitions Quadruped, reciprocal creeping, pull-to-stand, cruising, lowering to the floor with control. |
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Standing & walking Independent standing and walking attained; base of support, arm position, distance and surfaces managed. |
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Stairs Up and down: method (crawling, step-to, alternating), rail use, supervision needed. |
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Running, jumping & hopping Running with a flight phase, two-foot jump, jumping down and over, hopping on each foot, galloping and skipping. |
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Ball skills Throwing, catching and kicking a ball for age; accuracy, arm–leg pattern, and readiness. |
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Quality of movement Symmetry, variety of movement, effort, speed and the strategies the child relies on. |
📊 Standardized Test Scores
⚖️ Assessment: Balance & Postural Control
iStatic, dynamic, reactive and anticipatory balance, the sensory conditions under which it holds, and falls — timed where a stopwatch was used (single-leg stance each side, tandem stance).NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Static balance Single-leg stance each side and tandem stance, eyes open and closed; seconds held where timed. |
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Dynamic balance Beam or line walking, stepping over and around obstacles, turning, changing speed. |
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Reactive balance Response to a nudge or an unexpected surface change; ankle, hip and stepping strategies. |
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Anticipatory control Reaching outside the base of support, transitions between positions, catching a ball while standing. |
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Sensory conditions Balance on foam or a compliant surface, with vision removed, with head turns. |
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Falls & near-falls Frequency and circumstances reported and observed; fear of falling; injuries. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
🚶 Assessment: Gait
iWalking pattern, toe walking, asymmetries and compensations, speed and distance, varied terrain, and how any device or orthotic is used — observed barefoot and shod, with and without equipment.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Gait pattern Heel strike, foot progression angle, step length, cadence, base of support, arm swing, trunk movement. |
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Toe walking How often, on which surfaces, whether it corrects on cue or with heel-cord range; barefoot vs shoes. |
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Asymmetry & compensations Trendelenburg, circumduction, hip hiking, vaulting, knee hyperextension, crouch, scissoring. |
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Speed & distance Self-selected vs fast walking speed, distance tolerated, rest breaks; timed walk results where measured. |
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Varied terrain & community Curbs, ramps, uneven ground, grass, crowds, carrying an object while walking. |
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Devices & orthotics in gait What is used, how it is used, fit and wear pattern; gait with and without it. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
🎯 Assessment: Coordination & Motor Planning
iBilateral coordination, rapid alternating movement, sequencing and motor learning, timing and accuracy — how the child organises a movement they know and learns one they do not.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Bilateral coordination Jumping jacks, skipping, galloping, reciprocal arm–leg patterns. |
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Rapid alternating movements Foot tapping, heel–toe alternation, pronation–supination; rhythm and rate. |
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Motor sequencing & planning Imitating a movement sequence, an obstacle course, a new multi-step task. |
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Timing & rhythm Keeping a beat, timing a jump over a moving rope, catching on time. |
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Accuracy Kicking or stepping to a target, stepping into hoops, precision of foot placement. |
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Response to practice & feedback Change within the session with demonstration, verbal and visual cues, and repetition. |
📊 Standardized Test Scores
🔄 Assessment: Functional Mobility & Transfers
iGetting from one place or position to another in daily life: floor mobility, transfers, school and community distances, wheeled mobility, carrying a load — and the assistance and cueing each takes.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Floor mobility & floor-to-stand Moving on the floor, getting up from the floor (with or without hands, half-kneel, bear-stand), lowering with control. |
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Transfers Sit-to-stand and stand-to-sit, chair, toilet, bed, car seat, bath; the setup and help each takes. |
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School & community mobility Classroom, hallways, playground, bus steps, distances between rooms; keeping up with peers. |
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Wheeled mobility skills Propulsion, turns, ramps, curbs, brakes and safety in a wheelchair or mobility device where used. |
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Carrying & managing a load Backpack, lunch tray, opening doors, moving a chair. |
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Assistance & cueing across tasks Independent, supervision, contact guard, minimal to maximal assist; the cues that work. |
📊 Standardized Test Scores
🫁 Assessment: Endurance & Cardiorespiratory Fitness
iActivity tolerance, aerobic capacity, breathing during effort, fatigue and its effect on movement quality, and participation in active play — timed walk or run results where measured. Add when endurance limits participation.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Activity tolerance Sustained play, walking distance, recovery time; what ends the activity. |
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Aerobic capacity Timed walk or run, heart rate and perceived exertion during and after. |
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Breathing during activity Breathing pattern, effort, breath-holding, cough; response to exertion. |
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Fatigue & movement quality How gait, posture and coordination change as the child tires. |
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Active play, PE & sports What the child joins, sits out, or is excluded from; pacing strategies. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
🩹 Assessment: Pain
iA fuller pain picture than the screen on the history page: location, intensity on the scale used, pattern, pain with movement, effect on daily life and current management. Add when pain is part of the referral.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Pain report Location, intensity (scale used and score), quality, the child’s and caregiver’s words. |
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Pattern Onset, time of day, aggravating and easing factors, night pain. |
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Pain with movement or palpation Which movements, positions or tissues reproduce it; behaviour under load. |
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Effect on daily life Sleep, school attendance, play, sport, mood. |
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Current management Medication, rest, heat/ice, bracing, activity changes and how well each works. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
🦿 Assessment: Orthotics, Equipment & Positioning
iWhat the child uses now and how it fits and functions — orthotics, mobility equipment, seating and standers, adaptive and recreational equipment — and what should change. Add when equipment is part of the plan.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Orthotics Type, wear schedule, fit, skin check, condition; function with and without. |
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Mobility equipment Walker, gait trainer, wheelchair or stroller: fit, adjustment, how it is used and where. |
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Seating, positioning & standers Seating system, positioning devices, stander schedule; posture in each. |
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Adaptive & recreational equipment Adapted bike, bath and toilet equipment, car seat, playground access. |
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Recommended changes & next steps Adjustments, new equipment, trials, vendor and funding steps. |
📊 Standardized Test Scores
👶 Assessment: Head Shape & Neck
iThe torticollis and plagiocephaly picture in an infant: head tilt and rotation preference, cervical range each side, the sternocleidomastoid, cranial and facial asymmetry, positioning tolerance, and the associated hip screen. Add for an infant referral.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Head tilt & rotation preference Side and degree of tilt at rest; preferred direction of gaze and rotation; changes with position. |
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Cervical range Passive and active rotation and lateral flexion to each side; degrees where measured. |
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Sternocleidomastoid Tightness, a palpable mass, symmetry; response to stretch. |
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Cranial & facial asymmetry Flattening and its location, ear shift, forehead and cheek asymmetry; helmet status. |
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Positioning & tummy time Tolerance and duration of tummy time, sleep and carrying positions, preferences during feeding. |
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Associated findings Hip screen (asymmetric skin folds, limited abduction), foot posture, reflux or feeding side preference. |
📐 Measures
iOne row per measure: left and right side by side, the position it was taken in, and the condition chips that make the number comparable next time. A blank cell is NOT MEASURED — nothing is filled in for you. ◊ marks an area of note by rule (an asymmetry beyond the clinic's threshold, a reflex past its age, pain above 0), never an interpretation.📊 Standardized Test Scores
🌳 Assessment: Participation & Environment
iWhat the child does and wants to do at home, at school and in the community, the environmental barriers and supports, and the family’s priorities — the ICF participation picture the goals are written from.NC = No Concern (age-appropriate)
Concern = Significant difficulty observed
Document observations in Comments.
| Skill | No Concern | Concern | Comments |
|---|---|---|---|
Home Floor play, stairs, bath and bedtime routines, the yard; what the family adapts. |
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School & daycare Classroom, PE, recess, transitions, field trips; supports and accommodations in place. |
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Community Playgrounds, stores, transport, places of worship, visiting others; distances and access. |
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Play, sports & recreation What the child does now and wants to do; teams, lessons, adaptive programs. |
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Environmental barriers & supports Home layout, stairs, school setting, equipment access, transport. |
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Family priorities & the child’s goals What matters most to the family and to the child; the one thing that would change daily life. |
📊 Standardized Test Scores
🔁 Re-evaluation
What happened since the prior evaluation, and what you decide about each carried goal. The plan going forward — goals and the plan of care — is the next step, Plan & Goals.