Child Reflex Assessment Checklist
Complete this checklist to evaluate the presence and integration of primitive reflexes in children. Please provide accurate observations for each reflex.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Assessor's Name
*
First Name
Last Name
Assessment Date
*
-
Month
-
Day
Year
Date
Relationship to Child
*
Please Select
Parent/Guardian
Teacher
Therapist
Other
Primitive Reflex Checklist
*
Rows
Present
Integrated
Not Tested
Moro Reflex
1
2
3
Rooting Reflex
4
5
6
Palmar Grasp Reflex
7
8
9
Asymmetrical Tonic Neck Reflex (ATNR)
10
11
12
Symmetrical Tonic Neck Reflex (STNR)
13
14
15
Tonic Labyrinthine Reflex (TLR)
16
17
18
Spinal Galant Reflex
19
20
21
Babinski Reflex
22
23
24
Landau Reflex
25
26
27
Amphibian Reflex
28
29
30
Overall Motor Coordination
*
1
2
3
4
5
Behavioral Observations (e.g., attention, posture, movement patterns)
Recommendations for Follow-up
Would you recommend further evaluation or referral?
*
Yes
No
Not Sure
Additional Notes
Submit Assessment
Should be Empty: