| Client Name | |
| Facilitator Name | |
| Assessment Date | |
| Total Activities Selected | 0 |
| # Left Hits / # Right Hits | 0 / 0 |
| Category of Activity | |
|---|---|
| Participation sports | 0 |
| Spectator sports | 0 |
| Arts | 0 |
| Social Activities | 0 |
| Hobbies | 0 |
| Motor Skill Required | |
|---|---|
| Good fine motor skills | 0 |
| Fair fine motor skills | 0 | Good gross motor skills | 0 |
| Fair gross motor skills | 0 |
| Location | |
|---|---|
| Indoor activities | 0 |
| Outdoor activities | 0 |
| Home activities | 0 |
| Community activities | 0 |
| Equipment | |
|---|---|
| Minimal equipment | 0 |
| Moderate equipment | 0 |
| Maximum equipment | 0 |
| Social Attributes | |
|---|---|
| Individual activities | 0 |
| Small group activities | 0 |
| Large group activities | 0 |
| Cost | |
|---|---|
| Minimal cost | 0 |
| Moderate cost | 0 | Maximum cost | 0 |
| Physical Activity | |
|---|---|
| Minimal physical activity | 0 |
| Moderate physical activity | 0 |
| Maximum physical activity | 0 |
| Name | Times Selected | Type of Activity | Location | Social Attributes | Physical Activity | Motor Skill Required | Equipment Needed | Cost |