Print this page for each subject you test. Place a check mark in the box for the hand, foot, eye or ear that your subject uses in each test.
Part of Body | Test | Right Side | Left Side |
Hand | |||
Write name | ![]() | ![]() | |
Use scissors | ![]() | ![]() | |
Throw ball | ![]() | ![]() | |
Drink from cup (optional) | ![]() | ![]() | |
Fork to Mouth (optional) | ![]() | ![]() | |
Foot | |||
Kick ball | ![]() | ![]() | |
Step up stair | ![]() | ![]() | |
Step on object | ![]() | ![]() | |
Eye | |||
Look in tube | ![]() | ![]() | |
Sight a finger | ![]() | ![]() | |
Look through hole | ![]() | ![]() | |
Ear | |||
Listen to whisper | ![]() | ![]() | |
Listen to box | ![]() | ![]() | |
Listen through wall | ![]() | ![]() |
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