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Gross Motor Scale
Child:_______________________________ DOB:______________ CA:__________ Examiner:________________________________ Date:_________________________ Subscale A: Reflexes (1-11 months) Item # Month Position Score 1 Walking Reflex 2 supported 2 1 foot then other w/in 3sec standing 1 1 foot within 3 sec 0 Feet and legs remain still 2 Positioning Reflex 4 supine with 2 No arm or leg mvmt (ATNR-Integrated) head held 1 Positioned, but can move out of it 0 Reflex still present 3 Landau Reaction 6 horizontal 2 Raises head above suspended horizontal, extends trunk, raises hips and legs 1 Extends head, but not hips & legs 0 Head & hips below horiz. 4 Protecting Reaction 6 suspended 2 Extends arms, elbows & (Forward) horizontal bears weight on hands 1 Extends arms partially 0 Does not extend arms 5 Protective Reaction 6 sitting 2 Extends arm & bears (Side) weight 1 Extends arm, no weight bear 0 Falls on side 6 Protective Reaction 6 sitting 2 Breaks fall w/ 1 or 2 arms (Forward) supports self for 2 sec 1 Extends arm(s), falls 0 No arm extension 7 Righting Reaction 9 sitting 2 Ext. arm & head, returns (Forward) to upright sitting 1 Uses arms on floor, but Recovers 0 Fails to extend, falls 8 Protecting Reaction 10 sitting 2 Stops by ext arms & (Backward) supporting weight 1 Rotates trunk, extends arm, but falls 0 Fails to extend arm, falls Total Score: ______/
Gross Motor Scale
Child:_______________________________ DOB:______________ CA:__________ Examiner:________________________________ Date:_________________________ Subscale B: Supine Item # Age(mos) Score Comments (2; 1; 0) 1S – Rot Head 0 2 1 0 Lift/turn head R & L; 1 dir; no mvmt______ 1L – Thrust Legs 0 2 1 0 Moves legs together; separate; none_______ 2L – Side to back 0 2 1 0 Rolls to back both sides; 1 side; none______ 3L – Thrust Arms 0 2 1 0 Bend & straight arms 2x; 1x or 1 arm; none_ 6L – Symmetry 3 2 1 0 Hands & head to midline; 1 hand; none____ 8L – Rolling 4 2 1 0 Rolls to both sides; 1 side; no roll_________ 10L – Flex Legs 5 2 1 0 Feet to mouth/hands;hips 90˚ or 1 foot; none 11L – Ext Arms&Legs 5 2 1 0 Arms & legs in 5sec; 6-7sec; no mvmt_____ 13L – Flex Body 6 2 1 0 2 feet, 3 sec; 2 feet 1-2 sec or 1 foot 3sec; 0 15L – Ext Arm 6 2 1 0 Wt shift & reach 3sec; 1- 2 sec; no reach___ 16L – Rolling 7 2 1 0 Back →stomach both sides; 1 side; none___ 17L – Rolling 7 2 1 0 Rolls back→ stomach with rot. 2 sides; 1; 0 17S – Raise to Sit 10 2 1 0 Pulls to sit using chair; attempts, using chair; (toy on chair) remains on floor______________________ Subscale C: Prone Item # Age(mos) Score Comments (2; 1; 0) 5L – Ext. trunk 2 2 1 0 Lift head & trunk 45˚ 3 sec; 1-2sec; < 45˚__ 7L – Prop on forearms 4 2 1 0 Head & trunk 45˚ 5 sec; 3-4 sec; <3 sec____ 9L – Ext arms & legs 4 2 1 0 Ext A&L 3 sec; both1-2, AorL 3sec; none__ 12L – Ext Arm 6 2 1 0 shift & reaches toy; reach, but not full, none 14L – Pushing Up 6 2 1 0 WB on palms 5 sec; 3-4 sec; <3 sec_______ 18L – Move forward 8 2 1 0 moves 3 ft using arms; 2-3 ft; <2ft________ 19L – Raise Shldr& Butt9 2 1 0 Raise to hands & knees 5 sec, rocks; 1-5s; 0 18S – Sitting Up 10 2 1 0 Raises to sitting; attempts to sit; no mvmt__
Gross Motor Scale
Child:_______________________________ DOB:______________ CA:__________ Examiner:________________________________ Date:_________________________ 22L– Pivoting 9 2 1 0 Turns 90˚ both sides; 90˚ one side, <90˚___ 29L – Pivoting 11 2 1 0 Turns 180˚ on bottom; 90-179˚; <90˚______ 33L – Stand Up 12 2 1 0 Cross legged → stand <20˚ rotation of body; stands, but turns body 21-90˚; >90˚, no stand Subscale F: Hands and Knees Item # Age(mos) Score Comments (2; 1; 0) 20L - Creeping 9 2 1 0 Reciprocal creep 5 ft; 4ft or not reciprocal; ø 24L – Creeping 10 2 1 0 creeps over legs; creeps onto legs; not on leg 37L – Creep ↑ Stairs 14 2 1 0 Creeps up 2 steps; 1step; remains at bottom_ 39L – Creep ↓ Stairs 15 2 1 0 creeps backward 3 steps, no support; 1- 2 steps, no support; remains at start_________ Subscale G: Kneeling Item # Age(mos) Score Comments (2; 1; 0) 19S – Kneeling 13 2 1 0 Tall kneel 5sec while rot head; 2-4sec;<2sec Subscale H: Standing Balance Work/Preambulatory Item # Age(mos) Score Comments (2; 1; 0) 23L – Standing 9 2 1 0 Pulls to stand at object; attempts; no try____ 25L – Bouncing 10 2 1 0 Hold hands, bounce 3x; 1-2x; stiff legs____ 26L – Cruising 10 2 1 0 4 steps sideways; 1-3 steps; none_________ 27L – Lowering 10 2 1 0 Lowers to sit no fall; lowers, but falls, no try 28L – Stepping 10 2 1 0 Supported at trunk, 4 alt. steps; 2-3 steps; no 30L – Standing 11 2 1 0 Lets go of support, stands 5sec; 2 - 4sec; no__ 31L – Standing 11 2 1 0 Placed unsupported, stays 3 sec; 1-2 sec; 0_ Single Leg Stance Item # Age(mos) Score Comments (2; 1; 0) 20S – Stand on 1 Foot 31 2 1 0 Hands on hips 3sec; 1-2 sec; needs help____ 21S – Stand on 1 Foot 41 2 1 0 Hands on hips 5sec; 2-4sec; <2sec________
Gross Motor Scale
Child:_______________________________ DOB:______________ CA:__________ Examiner:________________________________ Date:_________________________ 23S – Stand on 1 Foot 45 2 1 0 Hands on hips, <20˚ sway, 5 sec; <20˚ sway, 2 - 4sec; <2sec or >20˚ sway_____________ 25S – Stand on 1 Foot 53 2 1 0 1 foot, then the other, hands on hips <20˚ sway, 6 sec ea foot; 1-5 sec ea foot; no_____ 27S – Stand on 1 Foot 59 2 1 0 Each foot, <20˚ sway, 10 sec; 5-8 sec; <5__ Other Stationary Skills Item # Age(mos) Score Comments (2; 1; 0) 22S – Stand on Tiptoes 43 2 1 0 Arms overhead, no foot mvmt 3sec; 1 - 2sec; moves feet or heels on floor_____________ 24S – Stand on Tiptoes 51 2 1 0 Arms overhead,<20˚ sway 8 sec; <20˚ sway 5 - 7 sec; <5sec or >20˚ sway_____________ 26S – Imitating Mvmt 57 2 1 0 Imitates 4 pos correctly; 1-3 correct; none__ (present 6 positions) ____________________________________ 46L – Stand (tandem) 19 2 1 0 Stand on line, 2sec, toe of back within 3” of front heel; 1 foot on line, attempt other; no_ Subscale I: Ambulation Stepping/Beginning Gait Item # Age(mos) Score Comments (2; 1; 0) 32L – Stepping 11 2 1 0 4 alt. steps, in place or move; 2-3 alt steps; 1 HHA no alt. steps __________________________ 34L – Walking 12 2 1 0 1 HHA alt, steps 8ft; 4-7ft; <4ft__________ 3 5L – Walking 12 2 1 0 Unaided 5 steps; 1-4 steps; no steps or sits__ 36L – Stand&Move 13 2 1 0 Picks up toy, return to stand takes 3 steps; 1- Balance 2 steps; loses balance or no try___________ Stairs Item # Age(mos) Score Comments (2; 1; 0) 40 L – Walk ↑ Stairs 15 2 1 0 ↑ 4 steps w/ support from wall or rail; 1- 3 steps with support; not on feet___________ 43L – Walk ↓ Stairs 17 2 1 0 ↓ 4 steps w/ finger assist; 1-3 steps; no_____ 52L - Walk ↑ Stairs 23 2 1 0 ↑ 4 steps no support; 4 steps using rail; no__ 53L - Walk ↓ Stairs 25 2 1 0 ↓4 steps no support; 1-3 ø support; uses rail
Gross Motor Scale
Child:_______________________________ DOB:______________ CA:__________ Examiner:________________________________ Date:_________________________ 56L – Walking Line 27 2 1 0 3steps on line, hands on hips, heels don’t touch toes; 1-2 steps, hands on hips; one foot off line__________________________ 68L – Walking Line 41 2 1 0 4ft on line, hands on hips, heels not touching toes; steps off 1 time, good form; >1step off 70L – Walk Line 41 2 1 0 8ft on line, ø step off, hands on hips, heels Forward not touching toes, <20˚ sway; steps off one time, good form; steps off >once or sways 75L – Walk Line 45 2 1 0 4ft w/out stepping off line >1x, hands on Backward hips, no heel-toe touch; steps off 2-5x, good form; steps off line>5x_________________ 78L - Walk Line 51 2 1 0 5 steps ø step off line, hands on hips & toes Backward touch heels; 2-4 steps good form; <2 steps Subscale J: Higher Level Activities Jumping Item # Age(mos) Score Comments (2; 1; 0) 49L – Jump Forward 23 2 1 0 4” forward, with balance; <4” balanced; step or fall_______________________________ 50L – Jump Up 23 2 1 0 Up 2” w/ feet together; feet barely leave floor, or leads w/ 1 foot; toes on floor_____ 51L – Jump Down 7” 23 2 1 0 Jumps ø assist, 1 foot may lead; steps down ø assist; needs help____________________ 55L – Jump Up 2” 25 2 1 0 Touches line or above; jumps btwn mark & (line on wall) line; toes on floor or below original mark__ 58L – Jump Down 29 2 1 0 Jumps ø assistance, can lead w/ 1 foot; steps (16-21”) down ø assistance, needs assistance_______ 61L – Jump Forward 31 2 1 0 24” with 2 footed takeoff & landing; 12-23” 2 - footed; <12”________________________ 62L – Jump Down 31 2 1 0 Jumps ø assistance, 2 footed takeoff& land; (18-24”) jumps leading w/ 1 foot, or falls; needs help 63L – Jump Hurdles 33 2 1 0 Jump over string 2-footed takeoff and land; (2” string) over, but 1 foot lead; steps over or remains_ 67L – Jump Forward 39 2 1 0 26”, 2-footed takeoff &landing; 12-25”; <
Gross Motor Scale
Child:_______________________________ DOB:______________ CA:__________ Examiner:________________________________ Date:_________________________ 72L – Jump Forward 43 2 1 0 6” forward, other foot does not touch; 2-5” One Foot no touch; <2” or other foot touches_______ 73L – Jump Up 3” 45 2 1 0 Touches line or above; jumps btwn mark & (line on wall) line; toes on floor or below original mark__ 76L – Jump Forward 47 2 1 0 30” forward 2 footed takeoff & land; 20-29” 2 footed; <20” or falls__________________ 81L – Jump Forward 53 2 1 0 36” forward 2 footed takeoff & land; 20-35” 2 footed; <20” or falls__________________ 82L – Turning Jump 53 2 1 0 Jump & turn 180˚, hands on hips, <20˚ body deviation; turns 90-180˚, good form; <90˚__ 84L – Jump Hurdles 57 2 1 0 Jump over string 2 footed takeoff & land; 1 (10” string) footed takeoff & landing; no jump over____ 87L – Jump Side 59 2 1 0 Jumps back & forth 3 cycles, hands on hips, (over line) feet together, ø touch line or pause; jumps 1 - 2 cycles; lands on line or pause btwn jump Other Activities Item # Age(mos) Score Comments (2; 1; 0) 59L – Walk on Toes 29 2 1 0 Walks on tiptoes 5 steps w/o heels touching floor; 1-4 steps same form; heels on floor__ 64L – Walk on Toes 33 2 1 0 Walks on toes entire length of line, hands on (4”x 8’ line) hips, heels up; 1-7ft; <1ft_______________ 77L – Hopping 47 2 1 0 5 hops on 1 foot, then 3-5 on other foot; 1 - 4 hops on 1 foot, 1-2 on other; none_____ 83L – Hop Forward 53 2 1 0 Hops one line to other, truns & hops back on (3 feet) other foot; 1 foot to line, turn 1-2 hops back; hops in place, does not reach line_________ 89L – Hopping speed 63 2 1 0 20ft in 6sec ø LOB or touch of opposite toe; (20 feet) 20ft in 7-10sec good form; <20ft or >10sec_ 80L – Galloping 51 2 1 0 10ft w/ weight transfer smooth & even, arms free; 5-9ft good form; <5ft______________ 86L – Skipping 57 2 1 0 Skips 8 steps, opposite arms & legs; 4- 7 steps, alternating; <4steps or stiff arms____ 88L – Skipping 61 2 1 0 Skips 10ft, good balance & rhythm; 5-9 feet; <4ft or arms stiff at sides_______________
Gross Motor Scale
Child:_______________________________ DOB:______________ CA:__________ Examiner:________________________________ Date:_________________________ 11 – Throwing Ball 27 2 1 0 Initiates throw by moving arm up & back, (overhand – 7ft.) ball travels 7ft forward in air; different initiation of throw, travels <6ft in air; drops ball or not forward____________________ 12 – Throwing Ball 29 2 1 0 Initiates throw by moving arm down& back, (underhand – 7ft.) ball travels 7ft forward in air; different initiation of throw, travels <7ft in air; drops ball or not forward____________________ 15 – Throwing Ball 39 2 1 0 Throws ball 10ft forward, good form; 3-9ft, (overhand – 10ft.) <3ft or different direction_______________ 16 – Hitting Target 39 2 1 0 Hits target 2/3 trials; hits 1/3 trials; fails to (underhand – 5ft from target) hit target____________________________ 18 – Hitting Target 43 2 1 0 Hits target 2/3 trials; hits 1/3 trials; fails to (overhand – 5ft from target) hit target____________________________ 19 – Throwing Ball 45 2 1 0 Throws ball 10ft w/ trunk rotation; 3-9ft w/ (underhand – 10ft.) trunk rotation; <3 ft, or no rotation________ 20 – Hitting Target 51 2 1 0 Hits target 2/3 trials; hits 1/3 trials; fails to (overhand – 12ft from target) hit target____________________________ 21 – Bouncing Ball 51 2 1 0 Bounces ball to wall so it hits floor once (stand 5ft from wall) then hits wall; hits floor >1x before wall; hits wall 1st^ or misses wall______________ 24 – Catch Bounced 68 2 1 0 Bounces & catches ball 2/3 trials, 1/3 trial; Ball (self bounce) fails to catch ball______________________ Kicking Ball ( 8” playground ball) Item # Age(mos) Score Comments (2; 1; 0) 4 – Kicking Ball 15 2 1 0 Lifts foot & contact ball; attempts; no try___ (place ball 6” in front of child) ____________________________________ 6 – Kicking Ball 19 2 1 0 Kicks ball 3ft forward w/ <45˚ deviation; (place ball 6” in front of child) kicks ball 3 ft w/ >45˚ deviation; kick <3ft_ 9 – Kicking Ball 23 2 1 0 Kicks ball 3ft w/ <20˚ deviation from mid.; (place ball 6” in front of child) Kicks 3ft, but deviates >20˚; <3ft or >20˚__ 13 – Kicking Ball 29 2 1 0 Kick ball forward 6ft. w/ opposite arm & leg mvmts, initiate kick w/ leg back& knee bent; 2 - 6 ft. same form; bad form or ball <2ft.___ 23 – Kicking Ball 68 2 1 0 Kicks ball so it travels 12 ft in air using opp. arm & leg mvmts, initiate kick w/ leg back& knee bent; 6-11ft in air, good form; <6ft___
