Name:

________________________________________________
Nickname: ________________Date of Birth:_________________________ Age: _______Sex:
GROSS MOTOR
SCOR COMMEN
TS
_______
E
1.
2.
3.
4.
5.
6.
7.
8.
9.
1
0.
1
1.
1
2.
1
3

9.
10
.

Climbs on chair or other

elevated piece of furniture like a
bed without help.
Walks backwards
Runs without tripping or falling.
Walks down stairs, 2 feet on
each step, with one held.
Walks upstairs holding handrail,
2 feet on each step.
Walks upstairs with alternate
feet without holding handrail.
Walks downstairs with alternate
feet without holding handrail.
Moves body parts as directed.
Jumps up.
Throws ball overhead with
direction.
Hops 1-3 steps on preffered
foot.
Jump and turn.

11
.

1.
2.
3.
4.
5.

Dances patterns/joins group

movement activities.
TOTAL SCORE

6.

GROSS MOTOR DOMAIN

1.
2.
3.
4.
5.
6.
7.
8.

FINE MOTOR DOMAIN

FINE MOTOR
SCOR
E
Uses 5 fingers to get food/toys
placed on flat surface.
Picks up objects with thumb
and index finger.
Display
a
definite
hand
preference.
Puts small objects in/out of
containers.
Holds crayon with all the
fingers of his hand making a
fist(i.e, palmar grasp)
Unscrews lid of container or
unwraps food.
Scribbles spontaneously.
Scribbles vertical and
horizontal.

COMME
NTS

7.
8.
9.
10
.
11
.
12
.
13
.
14
.
15
.
16
.
17
.
18
.

Draws circle purposely.

Draws a human figure( head,
eyes, trunk arms, hand
/fingers).
Draws a house using
geometric forms.
TOTAL SCORE
SELP-HELP DOMAIN
SELP-HELP
SCOR
E
Feeds self with finger food(e.g,
biscuits, bread) using fingers.
Feeds self using spoon with
spillage
Feeds self using spoon without
spillage.
Feeds self using fingers with
spillage.
Fedds self using fingers
without spillage.
Eats without need for
spoonfeeding during any meal.
Helps hold cup for drinking.
Drinks from with spillage.
Drinks from cup unassisted.
Gets drink for self unassisted.
Pours from pitcher without
spillage.
Prepares own food/snack.
Prepares meals for younger
siblings/family members when
no adults is around.
Participates when being
dressed(e.g., raises arms or
lifts leg).
Pulls down gartered short
pants.
Redmoves sando.
Dresses without assistance
including buttons and tying.
Dresses without assistance
except for buttons and tying.

19
.
20
.

COMME
NTS

21
.

22
.

23
.
24
.
25
.
26
.
27
.

Informs the adult only after he

has already urinated (peed) or
moved his bowels (poohed) in
his underpants.
Informs adult of need to
urinate (pee) or moved bowels
(pooh-pooh) so he can be
brought to designated place
(e.g. comfort room).
Goes to the designated place
to urinate (pee) or move
bowels (pooh) and never does
this is his underpants
anymore>
Goes to the designated place
to urinate (pee) or move
bowels (pooh) and never does
does this is his underpants
anymore.

Wipes/clean self after a bowel

movement..
Participates when bathing (e.g.
Rubbing with soap).
Washes and dries hands
without any help.
Washes face without any help.
Bathes withou any help.
TOTAL SCORE

1.
2.
3.
4.

RECEPTIVE LANGUAGE
RECEPTIVE LANGUAGE
SCOR
E
Points to family members
when asked to do so.
Points to 5 body parts on
himself when asked to do so.
Points 5 named picturd objects
when asked to do so.
Follws one-step instructions
that include simple
prepositions (e.g. in, on, under,
etc.)

COMMEN
TS

5.

1.
2.
3.
4.
5.
6.
7.
8.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10
.
11
.
12
.

Follows 2-step instructions that

include simple preposition.
TOTAL SCORE
EXPRESSIVE LANGUAGE DOMAIN
EXPRESSIVE LANGUAGE
PRESE
NT
Uses 5-20 recognizable words.
Uses pronouns (e.g. I, me, ako,
akin)
Uses 2-3 words verb-noun
combinations (e.g. hingi gatas).
Names objects in pictures.
Speaks in grammatically correct 23 word sentences.
Asks what questions.
Aks who questions.
Gives account of recent
experiences (with prompting) in
order of occurence using past
tense.
TOTAL SCORE

COGNITIVE DOMAIN
COGNITIVE
PRESE
NT
Looks at direction of fallen object.
Looks dor partially hidden object.
Immitates behavior just seen a
few minutes earlier.
Offers object but will not release
it.
Looks for completely hidden
object.
Exhibits simple pretend play
(feed, put doll to slep).
Matches objects.
Matches 2-3 colors.
Matches pictures.
Sorts based on shapes.
Sorts objects based on 2
attributes (e.g. size and color).
Arranges objects according to
size from smallest to biggest>

COMMEN
TS

13
.
14
.
15
.
16
.
17
.
18
.
19
.
20
.
21
.

22
.

Names 4-6 colors.

Copies shapes.

23
.

Names 3 animals or vegetables

when asked.
States what common household
item are used for.
Can assemble simple puzzles.

24
.

Demonstrates an understanding
of opposites by completing a
statement (e.g. Ang aso ay
malaki. Ang daga ay maliit.)
Points to left and right side of the
body.
Can state what is silly on wrong
with pictures (e.g. Ano ang mali
sa larawang ito?)
Matches upper and lower case
letters.
TOTAL SCORE

COMMEN
TS

1.
2.
3.
4.
5.
6.

SOCIAL EMOTIONAL DOMAIN

SOCIAL-EMOTIONAL
PRES
ENT
Enjoys watching activities of
nearby people or animals.
Friendly with strangers but
initially may show slight anxiety
or shyness.
Plays alone but likes to be near
familliar adults or brothers and
sisters.
Laughs or squels aloud in play.
Plays peek-a-boo (bulaga).
Rolls ball interactively with
caregiver/examiner.

COOME
NTS

Honors a simple bargain with

caregiver (e.g. can play outside
7.
Hugs or cuddles toys.
only after cleaning/fixing his
8.
Demonstrates
respect
for
room).
elders using terms like po
Watches
responsibly
over
and opo.
younger
siblings/family
9.
Shares toys with others.
members.
1Cooperates
Immitateswith
adult adults
activities
(e.g.
and
0.
cooking,
washing)
peers in group situations to
1minimize
Identifies
feelings
others.
quarrels
and in
conflicts.
1.
TOTAL SCORE
1
Appropriately
uses
cultural
2.
gestures of greeting without
much prompting (e.g. mano,
bless, kiss, etc.)
1
Comforts playmates/siblings in
3.
distress.
1
Persists when faced with
4.
problem or obstacle to his
wants.
1
Helps with family chores( e.g.
5.
wiping tables, watering plants,
etc.)
1
Curious about environment but
6.
knows when to stop asking
questions of adults.
1
Waits for turn.
7.
1
Asks permission to play with
8.
toy being used by another.
1
Defends
possessions
with
9.
determination.
2
Plays organized group games
0.
fairly (e.g. does not cheat in
order to win).
2
Can talk about difficult feelings
1.
(e.g. anger, sadness, worry) he
experiences.

Name: ________________________________________________ Nickname: ________________Date of Birth:_________________________ Age: _______Sex:

_______
STANDARD SCORE: ___________________
SCALED
DOMAINS
RAW SCORE
SUM OF SCALED SCORE:
SCORE
_______________
GROSS

FINE
SELF-HELP
RECEPTIVE
EXPRESSIV
E
COGNITIVE
SOCIOEMOTIONA
L