Child Movement Assessment Questionnaire Form
Please complete this questionnaire to help us assess your child's movement abilities and related observations.
Child's First Name
*
Child's Age (in years)
*
How would you describe your child's ability to walk steadily without assistance?
*
Very steady
Somewhat steady
Occasionally unsteady
Frequently unsteady
How easily does your child run, jump, or climb compared to other children of the same age?
*
Much less easily
1
2
3
4
Much more easily
5
1 is Much less easily, 5 is Much more easily
Can your child catch or throw a ball with accuracy?
*
Always
Often
Sometimes
Rarely
Rate your child's balance when standing on one foot.
*
1
2
3
4
5
How well does your child use their hands for tasks like drawing, stacking blocks, or using utensils?
*
Very poorly
1
2
3
4
Very well
5
1 is Very poorly, 5 is Very well
Does your child avoid certain playground activities or physical games?
*
Never
Rarely
Sometimes
Often
How would you describe your child's overall coordination?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Please share any additional observations or concerns about your child's movement abilities.
Submit Assessment
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