SI Clinical Assessment Worksheet

[Adapted from OTA-Watertown SI Clinical Assessment Worksheet]

Name: Examiner:
st nd rd th
1 Assessment date: 2 Assessment date: 3 Assessment date: 4 Assessment date:

General observations
Observed Not observed Comments
Reactions to examiner
Attempts to interact
Varied facial expressions
Affect appropriate

Reactions to assessment
Needs family support
Able to separate from family
Exploratory behaviour
Cooperates and complies with requests
Follows directions
Easily transitions between tasks

Notable behaviours
Aggressive behavior
Avoidance behavior
Attention seeking behavior
Sensory seeking behaviour

Arousal levels
Appropriate activity level
Filters out background information
Focuses on task at hand
Well-modulated voice
Organises own behavior to do a task

Observations of sensory modulation

Over- Under-
Appropriate Comments
responsive responsive
Response to proprioceptive input
Bouncing
Crashing
Pushing and pulling
Joint traction
Vibration

Response to vestibular input

Horizontal linear movement
Vertical linear movement
Angular movement
Rotary movement
Head tipped backwards
On or over uneven surfaces
Heights
Moving over large therapy ball
Moving over large therapy ball with
vision occluded/into backward space
Response to tactile input
Imposed touch
Unexpected touch
Light touch

Response to auditory input

External noise
Sudden loud noises
Distractibility
Defensive reactions
Notable behaviours (covers ears, grinds teeth, hums, screams, rocks)

Response to visual input

Material on walls/table
Moving objects/people
Distractibility
Defensive reactions (to lights, moving objects, window)
Notable behaviours (covers eyes, averts gaze, visual stimming)

Observations of sensory discrimination

Done easily Done with Unable Comments (include the quality of
difficulty motor performance)
Tactile discrimination
Hand (fine motor quality)
Manipulates objects within hand
Differentiate motions of fingers (not like
wearing mittens)
Manipulates objects without constant
visual monitoring
Holds and manipulates objects without
dropping
Recognises object in hand
(stereognosis)
Discriminates area of body touched
Notable behaviours (excessive touching,
fidgeting, rubbing, mouthing)
Mouth (oral-motor quality)
Notices food/drool around mouth
Swallows all food in mouth
Clear articulation
Foot
Orientates socks/shoes on feet
Feels when something sticks to feet

Proprioceptive discrimination
Can climb on and off play equipment
Moves with fluidity and rhythm
Can move into backward space (walking
backwards, climbing down a ladder)
Accurately judges leg/foot placement
when climbing, hopping, jumping,
balancing
Can perform slow, controlled
movements
Diadocokinesis
Sequential thumb-finger touching
Uses appropriate amount of force (DDK,
TFT, ball skills, handling of objects,
clapping)
Controls force of grasp and release
Can hold and maneuver tools efficiently

Vestibular discrimination
Can maintain balance standing still
Can stand with eyes closed
Adequate safety and balance while
moving
Can walk on uneven surfaces
Can maintain balance while swinging
Discriminates head position in space,
direction/speed of movement
(recognizes before falls)
Protective responses
Righting and equilibrium reactions
Apt co-contraction
Post-rotary nystagmus

Visual discrimination
Locates people, sounds in room
Localises objects with eyes while still
and moving
Uses hands and eyes together well
Finds objects in cluttered area (figure
ground)
Identifies partially hidden object (visual
closure)
Completes puzzles (visual-spatial skill)

Auditory discrimination
Localises direction of sound
Identifies and names specific noises
Notable behaviours (repeats questions,
perseverates on sounds/words)

Observations of sensory processing

Performance No change Performance Comments (note intensity, frequency,
increases decreases duration of inputs)
Potentially organising inputs
Deep pressure touch (under mats,
therapy ball)
Heavy work (push, pull, carry, weighted
objects)
Joint traction
Vibration
Bouncing/jumping
Crashing
Swinging (note type of movement)
Oral input (blowing, sucking, biting,
chewing)
Rhythmical activities (jumping,
swinging, singing, rhyming)
Adaptive responses: planning and spatial temporal adaptation
Done easily Done with Unable Comments
difficulty
Adaptive responses
Alternating contraction and relaxation
(pushes and pulls on swing)
Initiates activity and can complete it
independently
Initiates and sustains activity requiring
typical movements
Initiates and sustains activity requiring
new movements
Executes complex activity requiring new
movements
Executes complex activity requiring
timing and adaptation

Praxis and motor planning

Initiates new activities
Creates an effective plan of action
Prepares body for motor actions (feed
forward)
Independently modifies plan for greater
success
Sequences an activity
Accepts and adapts to alteration in
activity

Bilateral Coordination
Coordinates symmetrical motions of
UL’s/LL’s
Coordinates reciprocal motions of
UL’s/LL’s
Coordinates opposing actions of UL/LL’s
(one side stabilizes)
Coordinates opposing actions of
UL’s/LL’s (both sides different actions)

Projected action sequences

Accurately targets: child still + target
still
Accurately times and targets while
moving + target still
Accurately times and targets while still +
target moving
Accurately times and targets while
moving + target moving
Adapted by Nancy Raubenheimer, 2009