Online Assessment Log Format – Pure Souls Learning Foundation

BIO DATA
DEVELOPMENTAL MILESTONES/ HISTORY
MEDICAL HISTORY
SCHOOLING
SPEECH AND COMMUNICATION
BEHAVIOUR
SOCIAL SKILL
SENSORY ISSUES
DIET

Phone

BIO DATA

DATE OF OBSERVATION *

CHILD’S NAME *

DATE OF BIRTH *

AGE *

SEX *

Male Female

BIRTH POSITION *

CHILD’S DIAGNOSIS *

NAME OF PARENTS *

PHONE NUMBER *

HOME ADDRESS *

E-MAIL *

OFFICE ADDRESS OF DAD *

OFFICE ADDRESS OF MUM *

LENGHT OF CHILD’S PREGNANCY (IN MONTHS) *

ANY COMPLICATIONS DURING PREGNANCY? *

YES NO

MODE OF DELIVERY *

NORMAL BIRTH PLANNED CS EMERGENCY

REASON FOR CS

SERIOUS ILLNESS OR INFECTION AFTER BIRTH *

YES NO

If yes, please state the Illness/Infection

BIRTH HISTORY IN DETAILS *

DEVELOPMENTAL MILESTONES/ HISTORY

Provide the appropriate age at which your child began to do the following activities:

Sit *

Crawl *

Stand *

Walk *

Talk *

Feed self *

Use toilet *

Dress/Undress self *

MEDICAL HISTORY

Is your child on any medication? *

Yes No

If Yes, state the medication and why?

Any seizure? *

Yes No

Allergies? *

Yes No

Hearing test conducted? *

Yes No

When? *

Where? *

Result *

Brief Medical History *

SCHOOLING

SCHOOL ATTENDED *

SPECIAL MAINSTREAM SCHOOL

CURRENT GRADE *

ACADEMICS PERFORMANCE *

SPEECH AND COMMUNICATION

Conversational skill (Expressive)

Tick the appropriate answer

Smiles to person talking or gesturing *

Yes No

Protest by vocalising disapproval of actions *

Yes No

Indicate interest in a toy or object through eye gaze, reaching or vocalization *

Yes No

Please state which colour

Request continued action of familiar toy, song or activity by body movement, eye contact or vocalization *

Yes No

Make request by directing person’s attention *

Yes No

Indicate I don't like this by turning or pushing *

Yes No

Use words or sign to express needs *

Yes No

Seek adult’s assistance in exploring the environment through vocalisation *

Yes No

Pointing or other communication signal *

Yes No

Imitates sound or words made by persons *

Yes No

Sings rhymes and songs *

Yes No

Greet familiar persons *

Yes No

Response to communication (receptive)

Tick the appropriate answer

Appropriately reacts to tone of voice/or some facial expression *

Yes No

Turn to the direction from which name is being called *

Yes No

Responds with correct gesture to ‘up’ and ‘bye-bye’ *

Yes No

Responds to ‘no’ (i.e briefly stops activity) *

Yes No

Responds to ‘give me’ *

Yes No

Follows simple commands (spoken or signed) *

Yes No

Identifies most common objects when they are named *

Yes No

Appropriately responds to ‘Yes or no’ response to questions *

Yes No

Correctly follow 2-3 steps command *

Yes No

Brief narration of Expressive/Receptive language challenges *

BEHAVIOUR

Please tick as appropriate

1. Hurtful to self by: *

Hitting banging scratching biting pinching pulling out hair

2. Hurtful to others by: *

Hitting kicking biting pinching scratching pulling hair.

3. Destructive to property by: *

Hitting tearing or cutting throwing marking or scratching things breaking

4. Destructive Behaviour by: *

Picking fight laughing /crying without reason yelling or screaming complaining interrupting

5. Unusual or Repetitive Habits by: *

Pacing rocking grinding teeth eating dirt or other objects talking to self sucking hands or objects staring at object or into space Making odd faces or noises.

6. Socially Offensive Behaviour by: *

Talking too loudly spitting at others talking nonsense picking nose standing too close or touching others too much touching genitals.

7. Withdrawal or Inattentive Behaviour by: *

Keeping away from other people sleeping too much appearing sad or worried showing little concentration showing little interest in activities expressing Unusual fears Unable to sit still

8. Uncooperative Behaviour by: *

Refusing to obey instructions perform given tasks follow rules

SOCIAL SKILL

Smile at familiar person *

Yes No

Try to attract attention by making sound, smilling, eye contact or body language *

Yes No

Respond differently to family members and strangers *

Yes No

Take parts in simple group games and social activities *

Yes No

Plays in isolation *

Yes No

Approaches adult or peer to initiate play *

Yes No

Shows affection (e.g. hugs) *

Yes No

Spontaneously share with others *

Yes No

Say ‘thank you’ when appropriate *

Yes No

Enjoy rhymes and songs *

Yes No

Engage in conversation *

Yes No

SENSORY ISSUES

Smell everything in sight *

Yes No

Twirls or spin self frequently during play *

Yes No

Startled at loud noise *

Yes No

Avoid being touched *

Yes No

Touch everything in sight *

Yes No

Doesn’t react to pain such as cut *

Yes No

Hang on people or furniture *

Yes No

DIET

Is your child on special diet? *

Yes No

What types of food does your child eat? *

PARENT’S CONCERNS *

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