Directions: Please place a check mark next to each item that accurately describes the student. If you can’t evaluate an item, please write a question mark next to the box.
Cognitive Perceptual/Motor (con’t) Has poor comprehension of material Has clumsy and awkward movements
Has poor short-term memory for verbal stimuli Has poor speech communication
Has poor short-term memory for nonverbal stimuli
Has difficulty putting objects in correct sequence
Has limited attention span Has difficulty remembering sequence of
Has difficulty understanding oral directions objects
Has difficulty understanding written directions Has right-left confusion
Has difficulty following a sequence of directions Has poor gross-motor coordination
Misunderstands material presented at a fast pace Has poor fine-motor coordination
Has difficulty recalling story sequences Moves slowly
Has difficulty understanding teacher when he/she Has poor handwriting
moves around the room Has poor tactile discrimination
Has difficulty shifting ways of looking at or doing
Behavioral things Gives up easily
Has difficulty reasoning abstractly Has difficulty beginning tasks on time
Has difficulty conceptualizing material Has difficulty completing tasks on time
Uses problem-solving strategies inefficiently Asks questions constantly
Learns very slowly Is impulsive
Has poor long-term memory Has trouble starting and continuing tasks
Forgets newly learned skills
Has difficulty changing from one assignment to another
Language/Academic
Avoids doing work in class
Has difficulty decoding words Shifts often to other activities
Has poor reading comprehension Has difficulty working independently
Has poor expressive language Has difficulty playing quietly
Has poor listening comprehension Is easily distracted
Uses gestures instead of words Doesn’t seem to listen
Has difficulty rapidly naming objects Shows aggressive behavior
Has difficulty rapidly reading words Shows disruptive behavior
Has a speech impairment Talks excessively
Has difficulty producing rhymes Interrupts others often
Has difficulty recognizing similar phonemes Speaks out of turn (often blurts out)
Has difficulty arranging phonemes into words Makes comments not related to the topic
Has difficulty using verbal coding as memory aid Has difficulty remaining seated
Has difficulty using verbal coding as an aid in Fidgets often when seated
Rehearsal Does not arrive on time to class
Has poor grammar Fails to return on time to class
Has poor math computation skills Has limited persistence
Has limited math problem-solving skills Fails to do homework
Does not retain math facts Loses homework
Has poor spelling Seeks attention constantly
Has fluctuating performance Is unorganized
Has difficulty writing compositions Uses immature vocabulary
Does not know names of common objects Is slow to complete tasks
Perceptual/Motor
Behaves inappropriately
Has poor auditory perception Uses drugs or alcohol
Has poor visual perception Hurts others
Behavioral (Con’t) Social (con’t) Is cruel to animals Has difficulty making constructive
Talks about suicide contributions during group activities
Destroys others’ property Avoids others completely
Is out of chair when supposed to be doing work Has anger management problems
Has constant and repetitive behavior Displays inappropriate humor
Speaks slowly Seeks to manipulate others
Shouts or yells for no apparent reason Is rigid and opinionated
Has hallucinations Has unusual interest in sensational
Stutters violence
Injures self often Is fascinated with violence-filled
Bites nails entertainment
Bangs head
Affect/Motivation Holds breath Is easily frustrated
Does not tolerate changes in routine Shows anger quickly
Wanders aimlessly around room Has limited motivation
Is a daydreamer Is often anxious
Tires easily Is depressed or unhappy
Tells lies Has low interest in school work
Steals things Is self-critical
Has numerous physical complaints Is over excitable
Is frequently absent Is hyperactive
Has poor eye contact Has temper tantrums
Requires constant supervision Has unusual fears
Engages in dangerous behaviors Is easily annoyed
Prefers not to try new activities Frequently cries
Social
Is tens and fearful
Is immature Seldom shows emotion
Is stubborn Is shy or timid
Has low self-esteem Is upset by changes in routine
Is socially isolated Has wide mood swings
Has low popularity Feels hopeless
Has difficulty communicating interests
Self-Care Skills Has difficulty accepting criticism Has poor personal hygiene
Has limited social perceptiveness Has disheveled and unclean personal
Gives in to peer pressure appearance
Is uncooperative Fails to dress appropriately for weather
Has poor skills on playground Has poor table manners in cafeteria
Is overly compliant Fails to use free time appropriately
Is selfish Engages in self-stimulating behaviors
Seems suspicious of other people Has slumped posture
Refuses to share Has rigid, tense posture
Shows sexually provocative behavior Has atypical, inappropriate posture
Blames others for problems
Has difficulty seeking help
Has difficulty accepting help from teacher
Has difficulty accepting help from peers
Does not get along with other children
Does not offer opinions and answers when
asked
Does not enjoy group activities
Does not show concern for others’ feelings
and property
solves conflicts by shouting, fighting, or
intimidating others
Strengths Please list the child’s strengths in each of the following areas: