Physical Therapy Intake: Gross Motor Checklist

Child's name

Age

Client full name

Email

Is your child in constant motion and unable to sit still for an activity?

Yes No

Can your child sit 􀍞crisscross applesauce􀍟 on the floor without difficulty?

Yes No

Does your child prefer to W-sit all the time?

Yes No

Does your child prefer lying down on the floor vs sitting up?

Lying down Sitting Up

Does your child fall out of his􀍬her chair or appear to slouch and have difficulty maintaining the sitting position?

Yes No

Does your child get on his/her tummy and tolerate it well?

Yes No

Can your child crawl on hands and knees reciprocally?

Yes No

Did your child crawl before walking?

Yes No

Does your child get on/off the swing independently?

Yes No

Can your child swing by himself/herself on a regular playground swing?

Yes No

Does your child climb and play on playground equipment?

Yes No

Does your child have difficulty with changing surfaces 􀍾sidewalk to grass, carpet to wood, ramps, inclines, curbs?

Yes No

Does your child fall a lot or stumble and trip on objects

Yes No

Does your child have difficulty with stairs?

Yes No

What pattern does your child use with stair climbing?

Alternating feet Non-reciprocal

What amount of assistance does your child require climbing stairs?

1 Hand 2 Hands Independent

Can your child ride a tricycle or a bike?

Yes No

Can your child run?

Yes No

Can your child skip or gallop?

Yes No

Can your child jump?

Yes No

Can your child hop on one foot?

Yes No

Can your child stand on one foot?

Yes No

Can your child imitate simple motor movements

Yes No

Can your child throw/catch a ball?

Yes No

Does your child have difficulty learning new motor activities?

Yes No

Does your child fatigue easily

Yes No

Does he/she engage in active play with peers and siblings?

Yes No

Does your child prefer sedentary play or active play

Sedentary Active

Does your child appear loose jointed and floppy?

Yes No

Do your child's movements appear stiff and awkward?

Yes No