Paediatric OT sensory-motor assessment template and sample
A paediatric OT sensory-motor assessment format that links each finding to home and school routines, with sample entries and no test items.
✓Two findings tables, ready to fill
✓Links each finding to participation
✓Space for trial supports
Free · No sign-up · Saves in your browser · Built into healhab as “Sensory-Motor and Participation Assessment”
What's inside
Primary Participation Concerns
Settings and Routines Observed or Reported
Sensory and Regulation Profile
Motor and Visual-Motor Findings
Regulation, Attention, and Transitions
Environmental Facilitators and Barriers
Participation Strengths
Summary of Functional Impact
+ 3 more sections
Preview · 11 sections
Sensory-Motor and Participation Assessment
Patient
Patient ID
Date of birth
Assessment date
Therapy
Therapist
Languages
Referred by
Primary Participation Concerns
Primary participation concerns
Settings and Routines Observed or Reported
Contexts and routines
Sensory and Regulation Profile
Setting / Input
Observed or Reported Response
Participation Impact
Current Support
Motor and Visual-Motor Findings
Area
Finding
Functional Relevance
Posture / gross motor
Fine motor / hand use
Bilateral coordination
Visual-motor / visual-perceptual
Regulation, Attention, and Transitions
Regulation attention transitions
Environmental Facilitators and Barriers
Facilitators
Barriers
Participation Strengths
Participation strengths
Summary of Functional Impact
Functional impact summary
Recommendations and Trial Supports
Recommendations and trial supports
Follow-up and Outcome Monitoring
Follow up monitoring
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Primary Participation Concerns
The two or three hardest routines, each in a specific setting, with who raised it.
More guidance
Name the two or three routines or activities that are hardest for the child and the family right now. Describe each as a participation problem in a specific setting, and add who raised it. Avoid opening with skill terms. 'Cannot stay through the school assembly' gives the reader a reason to read your sensory findings.
2
Settings and Routines Observed or Reported
Where and when you observed, and which routines others described to you.
More guidance
List where and when you observed the child, and which routines others described to you. A child often looks different in a quiet clinic room than in a classroom of forty. Note the time of day, who was present and anything unusual about the day. If you could not observe a key setting, say so and plan a visit or ask for a short video.
3
Sensory and Regulation Profile
One row per setting: the child's response, its effect, and current support.
More guidance
Each row covers one setting or type of input: the child's observed or reported response, its effect on participation and the support used now. Write the response as behaviour and keep the source visible. If your clinic uses a licensed sensory questionnaire, it can inform this table; name it and report its results only as its manual allows, and do not copy its items into the template.
4
Motor and Visual-Motor Findings
Posture, hand use, bilateral coordination and copying, each with why it matters.
More guidance
Fill each row with what you observed and why it matters. Posture and gross motor: sitting tolerance, balance in play, stairs. Fine motor and hand use: grasp, in-hand manipulation, tool use. Bilateral coordination: opening a tiffin, cutting, threading. Visual-motor and visual-perceptual: copying, spacing, puzzles. Record any test by name with results as its manual states.
5
Regulation, Attention, and Transitions
How the child changes activity, recovers and stays with a task, and what helps.
More guidance
Describe how the child moves between activities, recovers after becoming upset and sustains attention under different conditions. Note what helps: a warning before change, a timer, a movement break, a familiar adult. Include how long recovery took and what the adult did. These details shape the trial supports later in the report.
6
Environmental Facilitators and Barriers
What in the child's surroundings helps and what makes participation harder.
More guidance
Use the two columns for what in the child's surroundings helps and what makes participation harder. Think about noise, light, seating, crowding, how predictable the routine is, which adults are available and what is expected of the child. Indian classrooms are often large and noisy, and homes may be shared with extended family. Describe these as facts that shape the plan, without judgement.
7
Participation Strengths
Activities the child enjoys and does well, and the conditions that help.
More guidance
Record the activities the child enjoys and does well and the conditions that bring out their best. Strengths often become the starting point for therapy activities and for motivation at home. Be as specific here as you are about difficulties. Parents notice when a report lists only problems.
8
Summary of Functional Impact
Your plain-language account of how the findings affect the routines named at the start.
More guidance
Write this section yourself as the treating therapist, using only the findings above. Explain in plain words how the sensory, regulation and motor findings together affect the child's participation in the routines named at the start. Do not add conditions or labels the report has not evidenced. State the limits of the assessment, such as a setting you could not observe.
9
Recommendations and Trial Supports
Supports to trial, by whom, where and for how long, with a review point.
More guidance
List what you recommend and which supports should be trialled, by whom, where and for how long. Frame supports as trials with a review point, since you will learn from how the child responds. Keep therapy recommendations separate from suggestions for school, which the school decides how to use.
10
Follow-up and Outcome Monitoring
When you will review, what you will look at, and who reports it.
More guidance
State when you will review, what you will look at and how the information will be gathered. Choose measures the family and school can report easily, such as the number of mornings the child got ready with one prompt. Link each monitoring point to a concern from the first section.
Paediatric OT sensory-motor assessment template and sample: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
Primary Participation Concerns
1. Leaves the classroom during music period most days (teacher). 2. Meals take over 45 minutes and end in tears (mother). 3. Refuses to wear school socks and tie (both parents).
Settings and Routines Observed or Reported
Observed: clinic gym, two morning sessions; lunch at home by video call. Reported: school morning routine (teacher, by phone); bath and bedtime (father).
Sensory and Regulation Profile
Setting: busy vegetable market. Response: covers ears and pulls toward the exit within 5 minutes (mother). Impact: family avoids taking him on errands. Current support: ear defenders, rarely tolerated.
Motor and Visual-Motor Findings
Bilateral coordination: steadies the paper with his left hand only after a reminder; cuts along a thick straight line but drifts at the corners. Relevance: craft work in class is left unfinished.
Regulation, Attention, and Transitions
When told play time is over, drops to the floor and cries for about 4 minutes. With a sand timer shown 2 minutes before, moved to the table after one prompt on 3 of 4 occasions.
Environmental Facilitators and Barriers
Facilitators: grandmother keeps a fixed bath time; class teacher allows a front-row seat. Barriers: open-plan flat with the television on most of the day; 50-minute school bus ride.
Participation Strengths
Builds with blocks on his own for about 20 minutes. Joins action rhymes when the group is small. Calm and chatty on morning walks with his grandfather.
Recommendations and Trial Supports
Trial a 2-minute warning with a sand timer before transitions at home for 3 weeks; parents to note responses in the home log. School to consider seating him at the end of the row during assembly.
Follow-up and Outcome Monitoring
Review in 8 weeks. Mother to note meal length on three days a week; teacher to note how many music periods he stays for each week.
Sensory-motor assessment vs OT case history form
Sensory-motor assessment
OT case history form
Completed by
The occupational therapist
Parent, carer or adult client, before or at the first visit
Content
Observed findings, functional impact and recommendations
Reported history, routines, preferences and priorities
Interpretation
Yes, by the treating therapist
None; answers are recorded as given
Timing
After observation and interview sessions
At intake, before assessment
Output
A report for the family, school and team
Background that feeds into the assessment
Tips and mistakes to avoid
Do
Observe at least one real routine, such as lunch or a class period.
Ask parents for a recent example: what happened, where, and what they did next.
For bilingual children, record which language the adult used for instructions.
Use the family's own words for what helps, then describe what you observed.
Where a paediatrician has named a condition, cite their report and keep your own findings descriptive.
Avoid
Labelling a child an 'avoider' or 'seeker' instead of describing responses in settings.
Copying items from a licensed sensory questionnaire into the report.
Recommending equipment with no link to a participation concern.
Relying on clinic observation alone when the concerns arise at school.
About this assessment report
A paediatric sensory-motor assessment describes how a child's sensory responses, regulation, posture, hand skills and visual-motor skills affect what they do at home, at school and in play. This free pediatric occupational therapy evaluation template gives you a findings table for each area and space for trial supports, without test items or scoring.
School reports trouble with noise, crowds or transitions
Handwriting, cutting or coordination concerns
Autistic children or those with attention differences
Before a sensory-motor goal plan or sensory diet
Read more
A shorter assessment for children referred mainly for regulation, coordination or handwriting concerns. It keeps attention on participation: the routines where the child struggles and the supports that already help.
The paediatric OT writes it after observation, caregiver interview and any tests the clinic uses. It describes sensory and motor participation only. It does not establish or confirm any condition, including autism.
Questions
What is a pediatric occupational therapy evaluation template?+
A report format for an OT evaluation of a child. This one covers sensory regulation, motor and visual-motor skills, and their effect on home, school and play. 'Evaluation' is the US term; Indian clinics usually say 'assessment'.
Can I use this template for an autistic child?+
Yes. The template describes the child's routines, responses and supports. It does not assess for autism or any other condition, so refer to the paediatrician's or psychologist's report where one exists.
Does this include a sensory questionnaire?+
No. Licensed sensory questionnaires belong to their publishers. If your clinic uses one, record its name, date and results as its manual allows.
How is this different from the comprehensive OT assessment?+
The comprehensive assessment covers every occupation for any age. This one is shorter, built around a sensory table and a motor table, for children referred for those concerns.
Is there a filled sample of this assessment?+
Yes. Each section guide shows a fictional sample entry with initials only. The summary of functional impact has no sample, because the treating therapist writes it from their own findings.
Is this template built into healhab?+
Yes. The Sensory-Motor and Participation Assessment is a Template Studio starter that clinics can duplicate, edit and publish as their own version.
Can I fill it in online and download a PDF?+
Yes. Fill it in online without signing up and download a PDF. Drafts stay in your browser.
