GROSS MOTOR DOMAIN

GROSS MOTOR MATERIALS/PROCEDURE PRESENT COMMENTS

Climbs on chair or other elevated
1. piece of furniture like a bed without Parental report will suffice.
help
MATERIALS: toy PROCEDURE:
Ask the child to walk backwards by
demonstrating this. Credit if the
2. Walks backwards child is able to walk backwards
without falling and holding on to
anything. Parental report will
suffice.
MATERIA: ball PROCEDURE:
Encourage the child to run by rolling
3. Runs without tripping or falling a ball across te floor. Credit if the
child can run fast and smoothly
without tripping or falling.
Walks down stairs, 2 feet on each
4. Parental report will suffice.
step, with one hand held
MATERIAL: toy PROCEDURE:
Place a toy in the middle of the step
and ask the child to walk up the stairs
to get the toy. Credit if the child
Walks up stairs holding handrail, 2
5. walks up walks up the stairs using the
feet on each step
handrail or wall for support and
places both feet on each step before
stepping on the next one. Parental
report will suffice.
MATERIAL: toy PROCEDURE:
Place a toy in the middle of the step
and ask the child to walk upstairs to
get the toy. Credit if the child walks
Walks upstairs with alternate feet
6. upstairs, alternating his feet as he
without holding handrail
steps on each successive step without
holding on to the handrail or wall for
support. Parenting report will
suffice.
MATERIAL: TOY PROCEDURE:
Place a toy in the middle of the step
and ask the child to walk downstairs
to eat the toy. Credit if the child
walks downstairs, alternating his feet
Walks downstairs with alternate feet as he steps on each successive step
7.
without holding handrail without holding on to the handrail or
wall for support. Do not give credit
if the child places both feet on the
step or uses the handrail or wall for
support. Parental report will
suffice.
PROCEDURE: Ask the child to raise
8. Moves body part as directed
both arms.
This must be elicited by the
9. Jumps up
interviews.
10. MATERIAL: ball
PROCEDURE: Give the child the
 ball and stand at least 3 feet away
from him. Ask the child to throw the
ball to you using an overhead throw.
You may show the child how to do it.
Credit if the child 1throws the ball
Throws ball overhead with Direction within your arm's reach between your
knees and head using an overhand
throw and not sideways or
underhand.
PROCEDURE: Ask the child to lift
his foot and hop at least three times
on his preferred foot. Credit if the
11. Hops 1 to 3 steps on preferred food
child is able to hop at least three
times on his preferred foot without
holding on to anything.
PROCEDURE: Ask the child to jump
while making a half-turn. Credit if
12. Jumps and turns
the child is able to do this without
tripping or falling.
Dances patterns / joins group
13. Parental report will suffice.
movement activities
TOTAL SCORE

FINE MOTOR DOMAIN

FINE MOTOR MATERIALS/PROCEDURE PRESENT COMMENTS
MATERIALS: small toy/object
PROCEDURE: Seat the child on the
parent's lap with his elbows at level
with the tabletop and his hands on the
Uses all 5 fingers to get food/toys table or flat surface. Drop a small
1.
placed on flat surface toy in front of him and attract his
attention by pointing to the toy or
tapping the table/flat surface. Credit
if the child picks up the toy, using all
5 fingers as if raking.
MATERIALS: any small toy or food
PROCEDURE: Place a toy/food in
front of the child and within his
Picks up objects with thumb and reach. Attract his attention by
2.
index finger tapping neat the toy/food. Credit if
the child uses the tips of his thumb
and index or forefinger to pick up the
toy/food.
MATERIAL: toy PROCEDURE:
Place the toy directly in front of the
child at midline (not to his left or his
3. Displays a definite hand preference right) and ask him to reach for this.
Credit if he uses the same hand 2 out
of 3 times. Parental report will
suffice.
MATERIALS: small objects,
Puts small objects in/out of
4. container This must be elicited by the
containers
interviews
5. Holds crayon with all the fingers of MATERIALS: crayon
 PROCEDURE: Present child with a
crayon and have him get this. Credit
if he holds it by wrapping all 5
fingers around as if making a fist.
his hand making a fist (I.e., palmar
Automatically credit this item if he
grasp)
uses the tips of all 5 fingers or his
thumb, index and middle fingers.
This must be elicited by the
interviews.
MATERIALS: Container with screw-
Unscrews lid of container or
6. on top or wrapped candy. This must
unwraps food
be elicited by the interviews.
MATERIALS: paper, pencil/crayon
PROCEDURE: Place a paper and
pencil/crayon on the table or flat
surface and ask the child to draw
anything he wants without showing
7. Scribbles spontaneously him what to do. Credit if the child
uses the tips of his thumb and any of
his other fingertips to grasp the
pencil/crayon and makes purposeful
marks on the paper (not accidental
marks).
MATERIALS: paper, pencil/crayon
PROCEDURE: Place a paper and
pencil/crayon on the table or flat
surface and ask the child to draw
vertical and horizontal lines after you
Scribbles vertical and horizontal have demonstrated these to him.
8.
lines Credit if the child produces a vertical
or horizontal line that is at least 2
inches long and does not divided or
vary from your vertical line by more
than 30 degrees. The lines may be
wavy but not broken.
MATERIALS: paper, pencil/crayon
PROCEDURE: Place a paper and
pencil/crayon on the table or flat
surface and ask the child to draw a
9 Draws circle purposely circle or a ball after you have
demonstrate it to him. Credit if the
child produces any curve that is
closed or nearly closed. Continuous
spiral motions are not credited.
MATERIALS: paper, pencil
PROCEDURE: Give the child a
pencil and a paper and ask him to
Draws a human figure (head, eyes, draw a picture of a person. Credit if
10.
trunk, arms, hands/fingers the child has draw 3 or more body
parts. A pair is considered one part
(eyes, ears, arms, hands, legs, and
feet)
11. Draws a house using geometric MATERIALS: paper, pencil
forms PROCEDURE: Give the child a
pencil and paper and ask him to draw
a picture of a house. Credit if the
 child has drawn at least the roof,
main frame, and a door or window.
TOTAL SCORE

SELF – HELP DOMAIN

SELF – HELP MATERIALS/PROCEDURE PRESENT COMMENTS
Feeds self with finger food (e.g. MATERIALS: bread, biscuits This
1.
biscuits, bread) using fingers must be elicited by the interviewer.
2. Feeds self using spoon with spillage Parental report will suffice.
3. Feeds self using spoon with spillage Parental report will suffice.
Feeds self using fingers without
4. Parental report will suffice.
spillage
Feeds self using spoon without
5. Parental report will suffice.
spillage
Eats without need for spoon feeding
6. Parental report will suffice.
during any meal
Note: The cup should not have a lid
7. Helps hold cup for drinking
or spout.
Ask the caregiver if the child can
drink from a cup/glass with some
8. Drinks from cup with spillage
spillage. The cup should not have a
lid or spout.
MATERIALS: drinking cup, water
9. Drinks from cup unassisted This must be elicited by the
interviewer.
10. Gets drink for self unassisted Parental report will suffice.
11. Pours from pitcher without spillage Parental report will suffice.
Ask the caregiver if the child can
prepare his own snack without help
12. Prepares own food/snack
except for getting items that are hard
to reach (e.g. bowl spoon).
Prepares meals for younger
13. siblings/family members when no Parental report will suffice.
adult is around
Participates when being dressed (e.g.
14. Parental report will suffice.
raises arms or lifts leg)
15. Pulls down gartered short pants Parental report will suffice.
16. Removes sando Parental report will suffice.
Dresses without assistance except for
17. Parental report will suffice.
buttons and tying
Material: small shirt w/button and
shoestring
Dresses without assistance including
18. PROCEDURE: Have the child
buttons and tying
demonstrate how to button in order
to credit this item.
TOILET TRAINING SUB - DOMAIN
Informs the
adult only after he has already
19. Parental report will suffice
urinated (peed) or moved his bowels
(poohed) in his underpants
Informs adult of need to urinate (pee)
or move bowels (poohpooh) so he can
20. Parental report will suffice
be brought to a designated place (e.g.
comfort room)
 Goes to the designated place to urinate
(pee) or move bowels (pooh) but
21. Parental report will suffice
sometimes still does this in his
underpants
Goes to the designated place to urinate
(pee) or move bowels (pooh) and
22. Parental report will suffice
never does this is his underpants
anymore
Wipes/Cleans self after a bowel
23. Parental report will suffice
movement (pooh)
BATHING SUB - DOMAIN
Participates when bathing (e.g.
24. Parental report will suffice
rubbing arms with soap)
Ask the caregiver if the child can
Washes and dries hands without any wash and dry his face without any
25.
help help or supervision except to turn
on/off faucets that are out of reach.
Ask the caregiver if the child can
wash and dry his face without any
26. Washes face without any help
help or supervision except to turn
on/off faucets that are out of reach
27. Bathes without any help Parental report will suffice
TOTAL SCORE

RECEPTIVE LANGUAGE
RECEPTIVE LANGUAGE MATERIALS/PROCEDURE PRESENT COMMENTS
PROCEDURE: Ask the child to point
Points to family member when asked
1. to his mother/caregiver. Credit if he
to do so
does so
PROCEDURE: Have the child point
Points to 5 body parts on himself to his eyes, nose, mouth, hands and
2.
when asked to do so feet. Credit if he can point to all
these.
MATERIAL: picture book
PROCEDURE: Show the child a
picture book (one picture per page)
Points to 5 named pictured objects
3. and ask him to point to the picture by
when asked to do so
saying “Where's the____?” Credit if
the child can use his finger to point to
at least 5 pictures
MATERIALS :block/toy
PROCEDURE Ask the child to put a
Follows one-step instructions that block/toy under the table; on the
4. include simple prepositions (e.g., in, table; in the bag. Do not point or use
on, under, etc.) gestures when giving the instructions.
Credit if the child is able to follow at
least one of the instructions.
MATERIALS: BLOCK/TOY
PROCEDURE: Ask the child to get a
block/toy from under the table and
Follows 2-step instructions that
5. then place it on the table. Do not
include simple prepositions
point or use gestures when giving the
instruction. Credit if the child is able
to follow
 TOTAL SCORE

EXPRESSIVE LANGUAGE
EXPRESSIVE LANGUAGE MATERIALS/PROCEDURE PRESENT COMMENTS
PROCEDURE: Ask the caregiver if
the child can clearly say 5-6 words
1. Uses 5-20 recognizable words
aside from mama and papa. This will
be the minimum number.
2. Uses pronouns (e.g. I, me, ako, akin) Parental report will suffice.
Uses 2-3 words verb-noun
3. Parental report will suffice.
combinations (e.g. hingi gatas)
MATERIALS: picture book
PROCEDURE: Show the child a
picture book, point to an object in the
4. Names objects in pictures book, then ask him to name this (e.g.
“Ano ito?”). Credit if the child can
say the correct name of at least 4
objects.
Speaks in grammatically correct 23
5. Parental report will suffice.
word sentences
6. Asks “what” questions Parental report will suffice.
7. Asks “who”' and “why” questions Parental report will suffice.
PROCEDURE: Ask the caregiver if
the child can recount recent
experiences in correct sequence and
Gives account of recent experiences
using past tenses correctly. The
8. (with prompting) in order of
caregiver can prompt him so he can
occurrence using past tense
complete what he is talking about
(e.g., tapos, ano pang nangyari)
Parental report will suffice.
TOTAL SCORE

COGNITIVE DOMAIN
COGNITIVE MATERIALS/PROCEDURE PRESENT COMMENTS
MATERIALS: spoon /ball
PROCEDURE: With the child
seated, get his attention and drop a
spoon/ball in front of him. Then
1. Looks at direction of fallen object
observe if his eyes look down as it
falls. Credit if the child can bring his
eyes and head down as the object
falls.
Imitates behavior just seen a few
2. Parental report will suffice.
minutes earlier
3. Offers object but will not release it Parental report will suffice.
4. Looks for completely hidden object MATERIALS: ball, small towel/cloth
PROCEDURE: With the child facing
you, hide a ball completely under a
5small towel and observe if he will
look under the towel. Credit if he
looks under the towel and gets the
 hidden ball
MATERIALS: doll or toy car/block
PROCEDURE: If the child is a girl,
Exhibits simple pretend play (feed, carry the doll and try to rock it to
5.
put doll To sleep) sleep. If the child is a boy, move the
toy car/block back and forth. Credit
if the child can imitate this.
MATERIALS: pairs of spoon, balls,
blocks PROCEDURE: Place one
spoon, one ball, and one block on the
table. (live the child the other set of
objects arranged in random order.
6. Matches objects Demonstrate a matching, response
(e.g. spoon to spoon) then return the
objects to the child. Say, “Put each
object on the one that is just like it.”
Credit if the child can match the
objects correctly.
MATERIALS: 3 pairs of crayons
(blue, red, yellow) PROCEDURE:
Place one crayon of each color on the
table or flat surface. Give the child
the other crayons arranged in random
7. Matches 2 – 3 color order. Demonstrate a matching
repose (e.g., red crayon with another
red crayon) then return the crayons to
the child. Say, “Put each crayon on
the one that is just like it.” Credit if
the child can match
MATERIALS: 3 pairs of picture
cards (e.g., pictures of an apple,
orange, banana) PROCEDURE:
Place one copy of each picture on the
table or flat surface. Give the child
the other pictures arranged in random
8. Matches pictures order. Demonstrate a matching
response (e.g., picture of an apple
with another apple) then return the
pictures to the child. Say, “Put each
picture on the one that is just like it.”
Credit if the child can match all the
pictures correctly.
MATERIALS: 4 pairs of different
shapes that are of the same size and
color. PROCEDURE: Show the child
the shapes. Tell the child, “Put
together the ones that are the same.”
After the child sorts and groups the
9. Sorts based on shapes shapes, point to the ones with the
same shape and ask. “Why did you
put these together?” Credit if the
child can group the same shapes and
say why they are the same (pareho
sila, pareho sila ng hugis/shape, puro
sila bilog).
10. Sorts objects based on 2 attributes MATERIALS: 4 pairs of the same
 shape that differ in size and color.
PROCEDURE: Show the child the
shapes. Tell the child, “Put together
(e.g., size and color)
the ones that are the same”. Credit if
the child can sort all the shapes
according to size and color.
MATERIALS: 4 pieces of graduated
sized squares and 4 pieces of
graduated sized circles
PROCEDURE: Show the child the
first set of squares spread out at
random on a table or flat surface.
Say, “Here are 4 squares. Look, I
can begin with the smallest, then the
next big one, until the biggest one.”
Arranges objects according to size Demonstrate how to arrange the
11.
from smallest to biggest squares. Then disarrange these and
tell the child, “Now you start with
the smallest, put the next one and the
next big one until the last one.”
Repeat this procedure using the
circles without demonstrating. Credit
if the child arranges at least one set of
shapes in correct order from smallest
to biggest. Allow one trial for each
set of shapes
MATERIALS; 6 papers of different
colors PROCEDURE: Ask the child,
12. Names 4 – 6 colors
“What color is this?” Credit if the
child can name 4 – 6 colors correctly
MATERIALS: Paper and pen/crayon
PROCEDURE: Let the child copy a
13. Copies shapes circle, triangle, and circle after
demonstrating how each of this is
done.
Names 3 animals or vegetables when Credit if the child can name 3
14.
asked animals or vegetables.
Credit if he can state the use of
States what common household
15. function of at least 2 household items
items are used for
like a bed and a drinking glass.
MATERIAL: simple 4 – 6 piece
16. Can assemble simple puzzles
puzzles
Demonstrates an understanding of
opposites by completing a statement Credit if the child can give an
17.
(e.g., Ang aso ay malaki, ang daga opposite word.
ay _____”)
PRCEDURE: Sit across the child and
ask “Show me your left hand.” Do
the same for the following: Right
hand, left foot, right knee, left
18. Points to left and right sides of body
shoulder, right eye, right knee, left
leg. Credit if the child can correctly
point out the left and right side on at
least 5 body parts as requested.
19. Can state what is silly or wrong with MATERIALS: A picture
pictures (e.g. Ano ang mali sa PROCEDURE: Show the pictured
 scenes to the child one at a time and
ask, “What is wrong with this
larawang ito?) picture?” Credit if the child correctly
identifies what made the picture
incorrect.
MATERIAL/s: Alphabet card with
20. Matches upper and lower case letters
upper and lower case letters.
TOTAL SCORE

SOCIAL – EMOTIONAL DOMAIN

SOCIAL – EMOTIONAL MATERIALS/PROCEDURE PRESENT COMMENTS
Enjoys watching activities of nearby
1. Parental report will suffice.
people or animals
Friendly with strangers but initially
2. Parental report will suffice.
may show slight anxiety or shynes
Plays alone but likes to be near
3. Parental report will suffice.
familiar adults or brothers and sisters
4. Laughs or squeals aloud in play Parental report will suffice.
5. Plays peek-a-boo (bulaga) Parental report will suffice.
Rolls ball interactively with
6. Parental report will suffice.
caregiver/examiner
7. Hugs or cuddles toys Parental report will suffice.
Demonstrates respect for elders
8. Parental report will suffice.
using terms like “po” and “opo”
9. Shares toys with others Parental report will suffice.
Imitates adult activities (e.g.,
10. Parental report will suffice.
cooking, washing)
Credit if the child can tell when the
caregiver is feeling happy, sad,
11. Identifies feelings in others
worried, etc. Parental report will
suffice.
Appropriately uses cultural gestures
12. of greeting without much prompting Parental report will suffice.
(e.g., mano, bless, kiss, etc.)
Comforts playmates/siblings in
13. Parental report will suffice.
distress
Credit if the child tries to solve the
problem instead of crying when
Persists when faced with a problem something stands in the way of what
14.
or obstacle to his wants he wants (e.g.., fastening a box of his
treasures with a string if the lid no
longer closes)
Helps with family chores (e.g.,
15. Parental report will suffice.
wiping tables, watering plants, etc.)
Credit (if the child asks questions
Curious about environment but
about things around him but knows
16. knows when to stop asking questions
when he is being “makulit” about the
of adults
topic.
17. Waits for turn Parental report will suffice.
Asks permission to play with toy
18. Parental report will suffice.
being used by another
Credit if the chid tries to hold on to
Defends possessions with
19. what is his when someone tries to
determination
grab this from him.
 Plays organized group games fairly
20. Parental report will suffice.
(e.g., does not cheat in order to win)
Can talk about difficult feelings
21. (e.g., anger, sadness, worry) he Parental report will suffice.
experiences.
Honors a simple bargain with
22. caregiver (e.g., can play outside only Parental report will suffice.
after cleaning / finishing his room
Watches responsibly over younger
23. Parental report will suffice.
siblings/family member
Cooperates with adults and peers in
24. group situations to minimize quarrels Parental report will suffice.
and conflicts.
TOTAL SCORE