Measure of Foundational Abilities -           Grade School
Please answer the following questions based on this student's typical behavior during the past month. Use the following rating scale :

Never: the behavior never or almost never happens
Occasionally: the behavior happens some of the time
Frequently: the behavior happens much of the time
Always: the behavior always or almost always happens
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Email *
Name of Child *
Name of Parent/Caregiver *
Date of Birth of Child *
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Balance, Gross & Fine Motor Control
Consistently walks on tiptoes *
Has trouble distinguishing between left and right *
Shifts preference of dominant hand use for tasks *
Has difficulty learning to type with both hands *
Avoids movement activities (swings, climbing, playground activities) *
Is constantly moving, tapping foot or pencil, drumming (may increase when trying to pay attention) *
Bumps into people/objects; gets too close to people; unaware of personal space *
Exhibits poor posture, slumps or slouches *
Has poor endurance, is weak and tires easily, avoids physical activity *
Has poor/illegible handwriting *
Exhibits poor balance and falls easily, avoids balance-related activities (scooter, bike-riding) *
Demonstrates poor sense of rhythm, timing *
Has difficulty learning fine motor tasks, such as writing, scissors, art projects *
Has difficulty learning new gross motor activities (bicycle, swimming, throwing, catching, climbing) *
Sensory
Seems bothered by textures on body (i.e. sticky items, sand/dirt, working with paint/glue, clothing fabrics/tags) *
Seems uncomfortable in certain clothes; has preferences for clothing textures *
Avoids many foods and/or foods with varying textures, such as fruit in yogurt or nuts in a candy bar *
Bothered by background noise (i.e., humming of lights, computers, fans) *
 Doesn't like being touched/over responds to unexpected touch/bumps *
Seems easily overwhelmed or upset by environmental noises (sirens, flushing of toilet, vacuums) *
Plays too roughly; hurts others inadvertently *
Is constantly on the move, seeks intense, crashing or rough play *
Avoids sustained eye contact *
Seems unaware/under-responds to body sensations: hunger, fullness, hot or cold, pain *
Doesn't seem to notice external sensory stimuli (touch, smells, noise) *
Has difficulty judging force required for task (breaks pencil lead, holds pencil tightly, throws ball too hard) *
Has an activity level that seems unusually high *
Has an activity level that seems unusually low *
Avoids contact with others; avoids crowded places (prefers being by self, standing aside from the group) *
Seems fearful when feet are off the ground (swinging, climbing) *
Constantly makes vocal noises, i.e., humming *
Social Emotional
Is easily overwhelmed; frustrated by activities, such as homework or chores *
Appears emotionally intense in most activities *
Has frequent mood fluctuations *
Appears anxious, bites nails, face and body are not relaxed *
Is easily upset/hurt; takes a long time to recover *
Responds with exaggerated emotion to external sensory stimuli *
Does not transition smoothly from one activity to another *
Has difficulty making and keeping friends *
Lacks confidence with new environments and new tasks *
Seems “needy”, lacks independence, has low self-reliance, has low self-esteem *
Prefers to interact with others 3 or more years younger *
Responds to situations in an immature manner for age *
Avoids social situations; prefers to be alone *
Is possessive with belongings, doesn’t share well *
Lacks tactfulness; acts impulsively *
Has difficulty self-regulating actions and/or emotions *
Auditory / Language
Says “What?” or “Huh?”, needs instructions repeated *
Has difficulty interpreting tone of voice - e.g. angry vs. joking *
Seems to have a delayed response with processing directions/questions *
Dislikes shrill sounds, or popping sounds, such as fireworks, balloons *
Has difficulty determining from what direction a sound is coming *
Confuses similar sounding words, such as 'mouth' and 'mouse' *
Is difficult to understand; doesn’t speak clearly; mumbles *
Speaks with monotone voice *
Has difficulty identifying and distinguishing between different sounds or letters *
Is fairly easily distracted by sounds; loses concentration *
Cannot identify words that rhyme *
Uses poor grammar; doesn't speak in complete sentences *
Needs hands-on or visual instructions along with verbal *
Is unable to recall the number of letters, numbers, or words in a series equivalent to his/her peers *
Has difficulty responding to simple questions (who, what, where) *
Exhibits difficulty organizing thoughts; stumbles over words *
Is unable to complete two unrelated commands (e.g., "Put your book away and wash your hands for dinner.") *
Has poor reading fluency *
Has difficulty with spelling and/or acquiring or using phonics rules *
Organization / Attention / Cognitive
Is easily distracted; is not able to stay on task (shorter attention span than peers) *
Has difficulty getting/finding clothes, getting dressed in the morning *
Forgets/loses items, such as jacket, hat, backpack, homework and other belongings *
Gazes into space/appears to be in own world *
Has difficulty sitting still; moves a lot, especially if trying to pay attention *
Interrupts others *
Has disorganized notes or poor study skills *
Forgets things just explained *
Has difficulty listening to stories; is unable to maintain attention to favorite ones *
Must re-read material several times to comprehend *
Is unable to keep up with new lesson; needs additional time and tutoring *
Has difficulty shifting attention from one activity or object to another (more so than peers) *
Has difficulty planning ahead (leaving the classroom or gym for another activity) *
Often fails to begin or complete tasks or projects *
Demonstrates poor judgment and reasoning skills; does not recognize cause and effect *
Is constantly making vocal noises to stay attentive (i.e., humming, talking to self) *
Has a tendency to ramble, can't "get to the point" *
Has difficulty organizing personal spaces/takes a long time to perform daily activities *
Has difficulty organizing thoughts on paper comparably to his/her peers *
Is unable to remember three or more verbal instructions at a time to complete a sequence or task *
Sleep
Lies awake for half an hour or more before falling asleep *
Awakens more than once during the night *
Cannot get back to sleep easily *
Has fitful sleep cycles (tosses, turns, restless) *
Moves to someone else's bed during the night (parent, sibling, etc.) *
Awakens during the night and is sweating, screaming and inconsolable *
Wakes up grouchy, irritable and mood persists throughout the day *
Feels sleepy and struggles to remain alert during day *
Is hard to wake up in morning *
Has this child experienced any traumatic events, changes in main caregivers, surgeries, abuse or neglect? *
Has this child ever been diagnosed with any of the following, check all that apply
Is this child currently receiving any therapy services? Check all the apply
Has this child received any therapy services in the past? Check all the apply
What are you hoping to accomplish at Tame Your Tiger Brain Training? *
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