Name: M.H. Date of birth: 2015 / 02 / 28 Age: 114 months
Date of assessment: 2024/09/12 *Use norms overleaf for children 3
to 8 yrs.
Hospital/unit: Cebu Doctors’ University Hospital
Date of motor accident:
Method of administration: Direct observation✔️ Interview with:
Area Score Age norm Is score due to
the brain injury?
Explain reasons
for giving this
score
SELF CARE
1.Eating 1 Yes ✔️
No
2.Grooming 1 Yes✔️
No
3.Bathing 1 Yes ✔️
No
4.Dressing– Upper
Body
2 Yes ✔️
No
5.Dressing– Lower
Body
1 Yes ✔️
N0
SPHINCTER
CONTROL
6.Toileting Yes ✔️
No
7.Bladder
management
Yes
No✔️
8.Bowel
management
Yes
No✔️
Self-care subtotal
TRANSFERS
9.Transfers:
Chair/Wheelchair
2 Yes ✔️
No
FORMCHECKBO
X No
Mode: W– Walk
C- Wheelchair B-
Both
10.Transfers:
Toilet
1 Yes ✔️
No
11.Transfers:
Tub/Shower
1 Yes ✔️
No
LOCOMOTION
12. Locomotion:
Walk/
Wheelchair/Crawl
2 Yes ✔️
No
Mode: W – Walk
C- Wheelchair
L- Crawl
B- Both
13.Locomotion:
Stairs
0 Yes ✔️
No
