Occupational Therapy Clinic Evaluation Form B-3 Page 2
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1
2
3
4Comments:
Postural Strength:
supine flexion __________seconds
prone extension __________seconds
scoliosis
kyphosis
lordosis
facilitated segment__________________________
Comments:
Reflexes
Protective Extension
N = No Apparent Deficit
ATNR
Forward
P = Partial Deficit
S = Severe Deficit
STNR
Backward
NE = Not Examined
NO = Not Observed
Righting Rxns
Right
Equilibrium Rxns
Left
Upper Extremity Coordination: (Proprioceptive Functions)
Slow Movements
Thumb Finger Sequencing
Forearm Rotation
Finger to Nose
Comments:
Oculomotor/Functional Visual Skills
Fixation
Convergence
Visual Attention
Divergence
Tracking/Pursuits
Eye Contact
Saccades
1◦ Visual Field
(peripheral or central)
Lateral Rotation on fixed visual point
Comments:________________________________________________________________________________
_________________________________________________________________________________________
Neurological Processing:
Attention
Arousal/Alertness
.docx
C:\Users\ronw.SECONNMFG\Desktop\Clinic OT Eval Form Todd Ped
Page 2 of 4
rev: 12/16/2008
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