50 chapter 5
EVALUATION OF PROGRESS—CHILD OVER AGE 5
RECORD
SHEET
5
Name______________________________________ Age________Disability_______________
CHART A
First visit (date
)
Daily activities
without
help
Feeding
1. How does the child eat? . . . . . . . . . . . . . . . 4
little lots of
help help
2 0
2. How does the child drink? . . . . . . . . . . . . . . 4
2 0
Second visit (date
)
without little lots of
help help help
4 2 0
4 2 0
Dressing and washing
3. Does child wash face and body? . . . . . . . . . . . 4
4. Does child dress? . . . . . . . . . . . . . . . . . . . 4
5. Does child put on orthopedic equipment? . . . . . . 4
Bowel and bladder care and control
6. Does child stay clean (bowel control)? . . . . . . . . 4
7. Does child clean herself after shitting? . . . . . . . . 4
8. Does child stay dry during the day? . . . . . . . . . 4
9. Does child stay dry at night? . . . . . . . . . . . . . 4
2 0
2 0
2 0
2 0
2 0
2 0
2 0
4 2 0
4 2 0
4 2 0
4 2 0
4 2 0
4 2 0
4 2 0
Mobility/transfers
10. Does child move from chair to bed and back? . . . . 4
11. Does child move from floor to bed and back? . . . . 4
Movement
12. Walks on flat surface? . . . . . . . . . . . . . . . . 4
13. Walks on uneven surface? . . . . . . . . . . . . . . 4
14. Climbs up and down stairs? . . . . . . . . . . . . . 4
15. Uses a wheelboard or wheelchair? . . . . . . . . . 4
16. Does child crawl? . . . . . . . . . . . . . . . . . . 4
2 0
2 0
2 0
2 0
2 0
2 0
2 0
4 2 0
4 2 0
4 2 0
4 2 0
4 2 0
4 2 0
4 2 0
Social activities/communication
17. Does child help with housework or farm work? . . . 4
18. Does child play with other children? . . . . . . . . . 4
19. Does child go to school? . . . . . . . . . . . . . . . 4
20. Does child speak? . . . . . . . . . . . . . . . . . . 4
21. Does child communicate with signs or gestures? . . 4
2 0
2 0
2 0
2 0
2 0
4 2 0
4 2 0
4 2 0
4 2 0
4 2 0
Total
Total
CHART B
First visit
Second visit
Quality of activities
make notes for
comparison here
Does child move about better? . . . . . . . . . . . . . . . . . . . . . . . . .
Does he sit in a better position? . . . . . . . . . . . . . . . . . . . . . . . .
Does he walk better (straighter, with less limp, or with less support)? . . . .
Does he walk farther, faster, or easier? . . . . . . . . . . . . . . . . . . . . .
Are his joints straighter (less contractures)? . . . . . . . . . . . . . . . . . .
hip? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
knee? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ankle? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Can the child do things he could not do before? . . . . . . . . . . . . . . . .
feeding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
bathing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
dressing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
toileting? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Does he play with things better? . . . . . . . . . . . . . . . . . . . . . . . .
Does he speak or communicate better? . . . . . . . . . . . . . . . . . . . .
Does he get along with other children better? . . . . . . . . . . . . . . . . .
Does he seem happier or more self-confident? . . . . . . . . . . . . . . . .
Has he improved or got worse in other ways? . . . . . . . . . . . . . . . . .
In what ways?
much a little same worse
better better
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
4 2
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
0 -4
Total
Disabled village Children