| Date |
|
|
|
|
|
1. Does your child eat and drink appropriately? (Al )
NOTE: Place a "Y," "S," or "N" by items a through e:
__________________________
__________________________
__________________________
__________________________
__________________________
|
|
|
|
|
- Does your child put a proper amount of food in his or her mouth, chew with mouth closed, and swallow the food before taking another bite? (Al . 1 )
- Does your child drink from a cup and return the cup to the table without spilling? (Al .2)
- Does your child eat and drink foods of different textures? For example, does your child eat soft foods such as bananas, drink liquids such as milk, and eat hard foods such as raw vegetables?(Al .3)
- Does your child choose to eat different kinds of food, such as dairy, meat, and fruit? (Al .4)
- Does your child eat and drink many kinds of foods using forks, spoons, and other utensils with little or no spilling? (Al .5)
|
|
2. Does your child help prepare and serve food? (A2)
NOTE: Place a "Y," "S," or "N" by items a through d:
__________________________
__________________________
__________________________
__________________________
|
|
|
|
|
- Does your child remove peels and wrappers before eating food? For example, your child peels a banana and removes a candy wrapper. (A2. I )
- Does your child use a knife to spread soft foods such as cream cheese or peanut butter onto bread or crackers? (A2.2)
- Does your child pour liquid from one container into another, such as juice into a cup? (A2.3)
- Does your child serve food from one container to another with a fork or spoon? For example, your child spoons applesauce from a jar into a bowl. (A2.4)
|
|
| 3. Does your child use the toilet without help? For example, your child walks to toilet/ adjusts clothing, uses toilet paper, flushes toilet, pulls up clothing, washes hands, and stays dry/unsoiled between trips. (B 1) |
|
|
|
|
4. Does your child take care of personal care needs? (B2)
NOTE: Place a "Y," "S," or "N" by items a through e:
_________________________
_________________________
_________________________
_________________________
_________________________
|
|
|
|
|
|
-
Does your child use a tissue to blow or wipe nose? (B2.1)
-
Does your child brush his or her own teeth? For example, your child puts toothpaste on brush, brushes teeth, and rinses mouth. (B2.2)
-
Does your child take off clothes, get into tub or shower, use soap to clean body, get a towel, dry off body, and put the towel back on the rack? (B2.3)
-
Does your child brush and comb his or her own hair? (B2.4)
-
Does your child wash and dry his or her face? For example, your child turns water on and off, uses soap, dries with a towel, and puts towel on the rack or throws paper towel away. (B2.5)
|
|
| 5. Does your child unfasten buttons and unzip zippers? (C1) |
|
|
|
|
|
6. Does your child choose, without help, the right clothes to wear for the time of day and weather conditions, and dress self only with a few reminders? For example, your child puts on pajamas at bedtime and puts on coat to go outside. (C2)
NOTE: Place a "Y," "S," or "N" by items a through f:
_________________________
_________________________
_________________________
_________________________
_________________________
|
|
|
|
|
|
- Does your child put long pants over both feet and pull them up to the waist? (C2. l )
- Does your child put on front-opening clothes (e.g., blouse, shirt, coat)? (C2.2)
- Does your child put on pullover clothes (e.g., T-shirt, dress, sweater)? (C2.3)
- Does your child put shoes on both feet? (C2.4)
- Does your child put on underpants, shorts, or skirts? (C2.5)
|
|
|
7. Does your child fasten buttons/snaps/Velcro fasteners when dressing? (C3)
|
|
|
|
|