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Preschool Educators Questionnaire
Preschool Educators Questionnaire
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Preschool Educators Questionnaire
Select Your Appointment Location*
Carrum Downs
Langwarrin
Mornington
Personal Details*
Student Date of birth
General Behaviour
Lacks concentration
Impulsive
Receptive/language problems
Gives up easily
Slow to complete task
Short attention span
Unable to play with peers
Visual Analysis
Easily distracted
Poor concentration
Unable to copy circles, shapes or letters
Traces, touches figures
Visual Problems
Clumsy
Complains of headaches
Sores eyes/rubbing
Complains of double vision
Tilts head to view
Becomes fatigued with near work
Short attention span
Red eyes/eye turns
Visual Spatial
Motor overflow
Does not cross midline
Unable to copy or draw letters/numbers?
Rotates body or paper when drawing.
Changes hands when writing
Uses alternative strategies for determining left and right.
Visual Motor
Pencil grip-normal
Thumb & 3 fingers
Thumb wrap
Unable to cut with scissors
Excessive finger tension
Unable to write own name
Posture - close working distance
Skews body to one side
Rotates body
Body Organisation
Poor organization
Forgets where things are
Cannot hop on one foot
Cannot jump and land with feet together
Unable to ride a bicycle and use pedals
Unable to climb with control.
Unable to walk on narrow line
Unable to stand on one foot with arms folded
Has the child had any other referrals or diagnosis?
Yes
No
