Considerations for Physical Therapy Evaluation Referral

Referral for a PT evaluation and the subsequent determination of need for PT services are IEP team decisions. The following checklist may assist the IEP committee in decision making, and may later be shared with the PT to highlight areas of concern regarding a student’s gross motor functioning.

Date ______________ Student Name ________________________________ DOB ______________

School _________________ Teacher’s Name ______________________________ Grade __________

Please complete the following questionnaire and indicate your level of concern regarding your student in the school environment. Additional issues may be added at the end.

Yes No Sometimes Comments

Seems weak (examples?) O O O

Gets tired easily O O O

Is distractible, impulsive

or unsafe when mobile O O O

Movements appear awkward O O O

Has difficulty imitating body postures

or learning new motor skills O O O

Has difficulty getting on/off the floor O O O

Has difficulty sitting on the floor

(eg., lays down, leans, takes up O O O

excessive space)

Doesn’t sit correctly in a chair or

at lunch table (i.e., slouches, leans O O O

on desk, falls)

Has difficulty carrying backpack,

materials, or lunch tray O O O

Has difficulty hanging up/taking down

coat or backpack from hook O O O

There are balance/safety concerns

in the bathroom O O O

Has difficulty opening doors O O O

Has difficulty standing still in line

(bumps into peers?) O O O

Has difficulty keeping pace with

classmates in hall O O O

Is clumsy, or tends to trip or fall

frequently O O O

Is unsafe, afraid or has difficulty going

up and down stairs O O O

Has difficulty remaining upright

to get on/off bus O O O

Has difficulty sitting securely

on the bus (seat belt needed?) O O O

Is reluctant to participate in

physical activity or group games O O O

Has difficulty walking on

uneven surfaces O O O

Is reluctant to access playground

structures (independently, O O O

with supervision or assistance?)

Has difficulty with running, jumping,

and other locomotor skills O O O

Has difficulty with ball skills

(throwing, catching, kicking?) O O O

O O O

O O O

O O O

O O O

O O O