Occupational Therapy Clinic Evaluation Form B-3 Page 3

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Vestibular
Proprioceptive
Tactile
Auditory
Visual
Olfactory
Oral
Social/Emotional
Motor Planning/Praxis:
Oral Motor/Feeding:
Ideation
Drooling
Food/Liquid Spillage
Planning/Execution
Lip Closure
Mouth/Tongue Posture
Comments: __________________
Straw Sucking
Intelligibility
___________________________
Chewing
Food Aversions
(temperature, texture, taste)
Drinking
Aversion to Toothbrushing
Blowing Bubbles
Comments:
Fine Motor/Perceptual:
Hand dominance
____ right
____ left
____ mixed
____Grasp patterns
____ In-hand Manipulation
____ Scissor skills
____Tool use
____ Fasteners
____ Pre-writing/writing
____ Bilateral coordination/crossing midline
____ Copying 2D/3D objects
____ Right/left discrimination
____Puzzles
____ Identify/match objects
Interpretation/Summary
.docx
C:\Users\ronw.SECONNMFG\Desktop\Clinic OT Eval Form Todd Ped
Page 3 of 4
rev: 12/16/2008

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