Sensory-Based Motor Skills Assessment
Please complete this form to evaluate the participant's sensory and motor skills across multiple domains.
Participant Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor's Name
*
First Name
Last Name
Participant Age
*
Sensory Processing
*
Rows
Never
Rarely
Sometimes
Often
Always
Responds to tactile input appropriately
1
2
3
4
5
Is distracted by background noise
6
7
8
9
10
Seeks movement activities
11
12
13
14
15
Shows sensitivity to lights or visual stimuli
16
17
18
19
20
Fine Motor Skills
*
1
2
3
4
5
Gross Motor Skills
*
1
2
3
4
5
Balance and Coordination
*
Rows
Poor
Below Average
Average
Good
Excellent
Maintains balance while walking
21
22
23
24
25
Coordinates hand and eye movements
26
27
28
29
30
Can hop on one foot
31
32
33
34
35
Catches or throws a ball
36
37
38
39
40
Observations/Comments
Self-Care Skills
*
Rows
Independent
Needs Assistance
Unable
Buttoning shirts
41
42
43
Using utensils
44
45
46
Tying shoelaces
47
48
49
Brushing teeth
50
51
52
Attention and Focus
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
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