Child Dyspraxia Symptom Checklist Form
Caregivers: Use this form to record and assess observations about a child’s dyspraxia-related symptoms.
Child’s First Name and Last Name
*
First Name
Last Name
Age of Child
*
Motor Skills Assessment
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty with handwriting
1
2
3
4
5
Trouble using scissors or cutlery
6
7
8
9
10
Problems with buttoning or tying shoelaces
11
12
13
14
15
Clumsiness (frequent tripping or bumping into things)
16
17
18
19
20
Which of these symptoms have you observed? (Select all that apply)
Difficulty planning movements
Avoids playground activities
Struggles with dressing independently
Difficulty with drawing or coloring
Speech or language challenges
Other
How much do these symptoms impact the child’s daily life?
*
Not at all
1
2
3
4
5
6
7
8
9
A great deal
10
1 is Not at all, 10 is A great deal
Does the child show frustration or low confidence related to motor tasks?
Yes
No
Sometimes
How frequently does the child avoid tasks that require coordination?
1
2
3
4
5
Do you notice any changes in the child’s social interactions due to these symptoms?
No change
Less social
More withdrawn
Other
Additional Observations or Comments
Submit Checklist
Should be Empty: