Functional Assessment of Children with Severe Disabilities
Martin E. Block, Ph.D., University of Virginia
Name: __________ School: __________ DOB: __________ Date: __________ Tester: ______________
Medical/Health Background
What is the child’s primary disability? __________________________________________________________________
What is the child’s secondary disabilities? __________________________________________________________________
Are there any movements or positions
child should or cannot do? Describe. __________________________________________________________________
Is the child on medication? __________________________________________________________________
If yes, describe type and purpose
Does the child any allergies? Describe. __________________________________________________________________
Does the child have a feeding tube? __________________________________________________________________
Does the child have a shunt? __________________________________________________________________
Does the child have scoliosis? __________________________________________________________________
If yes, does the child have rods in his back?
Does the child have any dislocations? __________________________________________________________________
If yes, where?
Does the child receive PT and/or OT? __________________________________________________________________
If yes, how often and who is the PT/OT?
1
Functional Position and Movement Analysis
Lying on Back
cannot move nonfunctional some functional functional
movements movements (best L/R/M) movement (best L/R/M)
head _________ _________ _________ _________
left arm _________ _________ _________ _________
right arm _________ _________ _________ _________
left leg _________ _________ _________ _________
right leg _________ _________ _________ _________
grasp - left _________ _________ _________ _________
release - left _________ _________ _________ _________
grasp - right _________ _________ _________ _________
release - right _________ _________ _________ _________
Lying on Stomach
cannot move nonfunctional some functional functional
movements movements (best L/R/M) movement (best L/R/M)
head _________ _________ _________ _________
left arm _________ _________ _________ _________
right arm _________ _________ _________ _________
left leg _________ _________ _________ _________
right leg _________ _________ _________ _________
grasp - left _________ _________ _________ _________
release - left _________ _________ _________ _________
grasp - right _________ _________ _________ _________
release - right _________ _________ _________ _________
2
Lying on Stomach over Wedge
cannot move nonfunctional some functional functional
movements movements (best L/R/M) movement (best L/R/M)
head _________ _________ _________ _________
left arm _________ _________ _________ _________
right arm _________ _________ _________ _________
left leg _________ _________ _________ _________
right leg _________ _________ _________ _________
grasp - left _________ _________ _________ _________
release - left _________ _________ _________ _________
grasp - right _________ _________ _________ _________
release - right _________ _________ _________ _________
Sitting in Wheelchair
cannot move nonfunctional some functional functional
movements movements (best L/R/M) movement (best L/R/M)
head _________ _________ _________ _________
left arm _________ _________ _________ _________
right arm _________ _________ _________ _________
left leg _________ _________ _________ _________
right leg _________ _________ _________ _________
grasp - left _________ _________ _________ _________
release - left _________ _________ _________ _________
grasp - right _________ _________ _________ _________
release - right _________ _________ _________ _________
3
Standing in Stander
cannot move nonfunctional some functional functional
movements movements (best L/R/M) movement (best L/R/M)
head _________ _________ _________ _________
left arm _________ _________ _________ _________
right arm _________ _________ _________ _________
left leg _________ _________ _________ _________
right leg _________ _________ _________ _________
grasp - left _________ _________ _________ _________
release - left _________ _________ _________ _________
grasp - right _________ _________ _________ _________
release - right _________ _________ _________ _________
Standing in Gait Trainer
cannot move nonfunctional some functional functional
movements movements (best L/R/M) movement (best L/R/M)
head _________ _________ _________ _________
left arm _________ _________ _________ _________
right arm _________ _________ _________ _________
left leg _________ _________ _________ _________
right leg _________ _________ _________ _________
grasp - left _________ _________ _________ _________
release - left _________ _________ _________ _________
grasp - right _________ _________ _________ _________
release - right _________ _________ _________ _________
4
Sitting/Standing/Rolling
Sitting
Always Usually Sometimes Never Comments
sits independently for 30 seconds or more _____ _____ _____ _____ __________
demonstrations righting response in sitting _____ _____ _____ _____ __________
sits for 10 seconds independently _____ _____ _____ _____ __________
sits for 5 seconds independently _____ _____ _____ _____ __________
needs minimal support to sit _____ _____ _____ _____ __________
needs significant support to sit _____ _____ _____ _____ __________
Standing
Always Usually Sometimes Never Comments
stands on floor independently or with support from _____ _____ _____ _____ __________
walker for 30 seconds or more
demonstrates righting responses in standing _____ _____ _____ _____ __________
stands on floor independently or with support from _____ _____ _____ _____ __________
walker for 10 seconds or more
stands on floor independently or with support from _____ _____ _____ _____ __________
walker for 5 seconds or more
stands on floor with support person _____ _____ _____ _____ __________
cannot stand on floor even with support person _____ _____ _____ _____ __________
Rolls Over
Always Usually Sometimes Never Comments
does complete log roll _____ _____ _____ _____ __________
rolls from back to stomach independently _____ _____ _____ _____ __________
rocks independently from side to side _____ _____ _____ _____ __________
lifts head independently when placed on back _____ _____ _____ _____ __________
attempts to lift head when placed on back _____ _____ _____ _____ __________
5
Functional Mobility
Independent Walking
Always Usually Sometimes Never Comments
walks independently, avoids obstacles, can _____ _____ _____ _____ __________
change directions, can stop and start
takes 10 or more independent, reciprocal steps _____ _____ _____ _____ __________
takes 3-7 independent, reciprocal steps _____ _____ _____ _____ __________
Gait Trainer
Always Usually Sometimes Never Comments
walks independently, avoids obstacles, can _____ _____ _____ _____ __________
change directions, can stop and start
takes 10 or more independent, reciprocal steps _____ _____ _____ _____ __________
takes 5-10 independent, reciprocal steps _____ _____ _____ _____ __________
takes 1-2 independent, reciprocal steps _____ _____ _____ _____ __________
tries to move legs or moves legs with assistance _____ _____ _____ _____ __________
Electric Wheelchair
Always Usually Sometimes Never Comments
moves chair independently, avoids obstacles, _____ _____ _____ _____ __________
changes directions, stops and starts
moves chair forward 20' or more independently _____ _____ _____ _____ __________
moves chair forward 5-10' or more independently _____ _____ _____ _____ __________
moves chair forward 1-5' or more independently _____ _____ _____ _____ __________
places hands on control of chair independently _____ _____ _____ _____ __________
places hand on controls of chair with assistance _____ _____ _____ _____ __________
Manual Wheelchair
Always Usually Sometimes Never Comments
moves chair independently, avoids obstacles, _____ _____ _____ _____ __________
changes directions, stops and starts
moves chair forward 20' or more independently _____ _____ _____ _____ __________
moves chair forward 5-10' or more independently _____ _____ _____ _____ __________
moves chair forward 1-5' or more independently _____ _____ _____ _____ __________
places hands on rims of chair independently _____ _____ _____ _____ __________
places hand on rims of chair with assistance _____ _____ _____ _____ __________
6
Functional Physical Fitness
Needs Significantly
Adequate Improvement Inadequate Not Observed
Functional upper body strength
(e.g., throw things, hold things, carry things) _____ _____ _____ _____
Functional lower body strength _____ _____ _____ _____
(e.g., kicking a ball, jumping, walking)
Functional flexibility _____ _____ _____ _____
(e.g., bend to pick up objects, ROM to perform
simple activities requiring stretching, bending)
Functional endurance _____ _____ _____ _____
(e.g., does not get tired doing simple, repetitive
activities in PE, does not need to sit and rest)
Body composition _____ _____ _____ _____
(e.g., general appearance – too heavy or too trim)
Comments regarding functional fitness: _____________________________________________________________________
7
Ball Skills
Grasp/Release/Toss ___ in gait trainer or stander ___ from wheelchair ___ lying on back ___ lying on stomach
Always Usually Sometimes Never Comments
grasps then tosses object independently 2' _____ _____ _____ _____ __________
grasps then tosses object independently 1-2' _____ _____ _____ _____ __________
grasps then tosses object independently 5-10" _____ _____ _____ _____ __________
grasps then tosses object independently 1-3" _____ _____ _____ _____ __________
grasps, holds, and drops object away from body _____ _____ _____ _____ __________
grasps, holds, and drops object independently _____ _____ _____ _____ __________
grasps and holds object; inconsistent release _____ _____ _____ _____ __________
grasps and holds object; cannot release _____ _____ _____ _____ __________
grasp and holds object for 10-15 seconds _____ _____ _____ _____ __________
grasps and holds object for less than 10 seconds _____ _____ _____ _____ __________
grasps and holds object with assistance _____ _____ _____ _____ __________
Kicking ___ in gait trainer or stander ___ from wheelchair ___ lying on back ___ lying on stomach
Always Usually Sometimes Never Comments
kicks ball forward 5-10' _____ _____ _____ _____ __________
kicks ball forward 3-5' _____ _____ _____ _____ __________
kicks ball forward 1-2' _____ _____ _____ _____ __________
puts foot next to ball and pushes ball forward _____ _____ _____ _____ __________
puts foot next to ball and touches ball _____ _____ _____ _____ __________
needs assistance to put foot on ball _____ _____ _____ _____ __________
8
Sensory Processes and Sensitivity
Visual Abilities ___ Excellent: vision is primary mode for information
___ Good but minimal deficits; vision is primary mode for information
___ Fair but moderate deficit; vision is used but misses some information
___ Poor with moderate deficit, residual vision is used but minimally
___ Severe deficit; vision is not used at all
Visual Sensitivity ___ Enjoys visual stimulation
___ Mildly sensitive to visual stimulation
___ Severely sensitive to visual stimulation
Hearing Abilities ___ Excellent: hearing is used for information
___ Good but minimal deficits; hearing is used mode for information
___ Fair but moderate deficit; hearing is used but misses some information
___ Poor with moderate deficit, residual hearing is used but minimally
___ Severe deficit; hearing is not used at all
Hearing Sensitivity ___ Enjoys auditory stimulation
___ Mildly sensitive to auditory stimulation
___ Severely sensitive to auditory stimulation
Kinesthetic Abilities ___ Excellent: sense of touch; can tell if he/she is being touched
___ Good but minimal deficits; hearing is used mode for information
___ Fair but moderate deficit; hearing is used but misses some information
___ Poor with moderate deficit, residual hearing is used but minimally
___ Severe deficit; hearing is not used at all
Kinesthetic Sensitivity ___ Enjoys being touched
___ Mildly sensitive to touch
___ Severely sensitive to touch
9
Communication
Receptive Language
Always Usually Sometimes Never Comments
understands all types of verbal commands _____ _____ _____ _____ ___________________
understands simple verbal commands _____ _____ _____ _____ ___________________
understands one word verbal commands _____ _____ _____ _____ ___________________
written words _____ _____ _____ _____ ___________________
picture symbols _____ _____ _____ _____ ___________________
real pictures _____ _____ _____ _____ ___________________
environmental cues (e.g., foot prints) _____ _____ _____ _____ ___________________
gestures _____ _____ _____ _____ ___________________
demonstrations _____ _____ _____ _____ ___________________
physical assistance _____ _____ _____ _____ ___________________
Expressive Language
Always Usually Sometimes Never Comments
understands all types of verbal commands _____ _____ _____ _____ ___________________
understands simple verbal commands _____ _____ _____ _____ ___________________
understands one word verbal commands _____ _____ _____ _____ ___________________
written words _____ _____ _____ _____ ___________________
picture symbols _____ _____ _____ _____ ___________________
real pictures _____ _____ _____ _____ ___________________
environmental cues (e.g., foot prints) _____ _____ _____ _____ ___________________
gestures _____ _____ _____ _____ ___________________
demonstrations _____ _____ _____ _____ ___________________
physical assistance _____ _____ _____ _____ ___________________
10
Play Behaviors and Awareness of Others
Play Behaviors (with others)
Always Usually Sometimes Never Comments
Cooperative play with others _____ _____ _____ _____ ___________________
Associative (interactive) play with others _____ _____ _____ _____ ___________________
Parallel play with others _____ _____ _____ _____ ___________________
Exploratory or sensory play _____ _____ _____ _____ ___________________
Autistic or unoccupied play _____ _____ _____ _____ ___________________
Play Behaviors (with objects)
Always Usually Sometimes Never Comments
Shares objects with others; plays appropriately _____ _____ _____ _____ __________________
Parallel play with objects; plays appropriately _____ _____ _____ _____ ___________________
Plays alone, appropriate exploratory/sensory play _____ _____ _____ _____ ___________________
Plays alone, inappropriate use of objects _____ _____ _____ _____ ___________________
Awareness of Others
Always Usually Sometimes Never Comments
Is aware of peers and seeks out peers _____ _____ _____ _____ ___________________
Is aware of peers; will play with peers if asked _____ _____ _____ _____ ___________________
Is aware of peers; prefers to play alone _____ _____ _____ _____ ___________________
Wants to be alone; resists playing with peers _____ _____ _____ _____ ___________________
Other Behaviors
Always Usually Sometimes Never Comments
Enjoys following directions; tries his/her best _____ _____ _____ _____ ___________________
Will follow directions; usually gives good effort _____ _____ _____ _____ ___________________
Needs extra cues/incentives to follow directions
but will follow directions 50% of time _____ _____ _____ _____ ___________________
Needs extra cues/incentives to follow directions
but will follow directions 25% of time _____ _____ _____ _____ ___________________
Does not follow directions even with incentives _____ _____ _____ _____ ___________________
May run wander or run away when given directions _____ _____ _____ _____ ___________________
May become aggressive when given directions _____ _____ _____ _____ ___________________
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