Child Motor Skills Assessment
Evaluate and record a child's gross and fine motor skills development.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Male
Female
Other
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator's Name
*
First Name
Last Name
Gross Motor Skills Assessment
*
Rows
Not Yet
Emerging
Mastered
Walks independently
1
2
3
Runs smoothly
4
5
6
Jumps with both feet
7
8
9
Climbs stairs
10
11
12
Balances on one foot
13
14
15
Fine Motor Skills Assessment
*
Rows
Not Yet
Emerging
Mastered
Grasps small objects
16
17
18
Draws simple shapes
19
20
21
Stacks blocks
22
23
24
Uses scissors
25
26
27
Buttons clothing
28
29
30
Hand Dominance
Right
Left
Mixed/Undetermined
Attention and Participation During Assessment
1
2
3
4
5
Additional Observations
Recommendations or Next Steps
Submit Assessment
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