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| Name: | ________________________ | Date of Birth: | ________________________ |
| School: | ________________________ | Grade: | ________________________ |
| Motor Skills | Mostly | Sometimes | Never |
| Shows interest in putting thoughts down in print | _______ | _______ | _______ |
| Able to print and write with ease | _______ | _______ | _______ |
| Interested in and enjoys physical activity (e.g. walking., skipping, throwing) | _______ | _______ | _______ |
| Demonstrates age-appropriate ability in physical activity (as above) | _______ | _______ | _______ |
| Able to move, balance, handle materials | _______ | _______ | _______ |
| Participates in activities to develop upper body strength | _______ | _______ | _______ |
| Can control stops, starts, changes of direction at different speeds | _______ | _______ | _______ |
| Develops patterns of action using the body/equipment alone | _______ | _______ | _______ |
| Develops patterns of action using the body/equipment with a partner | _______ | _______ | _______ |
| Participates effectively in group games | _______ | _______ | _______ |
| Shows agility, confidence, ingenuity and precision in fine motor skill activities | _______ | _______ | _______ |
| Shows agility, confidence, ingenuity and precision in gross motor skill activities | _______ | _______ | _______ |
| Demonstrates agility, confidence, ingenuity, and control in using body/equipment to solve problems requiring coordination of thought and physical activity | _______ | _______ | _______ |
| Comments |
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| Completed by: | ____________________________________________________________________ |
| Relationship to student: | ____________________________________________________________________ |
| Date: | ____________________________________________________________________ |
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Last update: September 1998 Branch Contact |