Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g. you've seen it once or twice), please answer as if the child does not do it.
| 1. Does your child enjoy being swung, bounced on your knee, etc? |
Yes
No
|
| 2. Does your child take an interest in other children? |
Yes
No
|
| 3. Does your child like climbing on things, such as up stairs? |
Yes
No
|
| 4. Does your child enjoy playing peek-a-boo / hide-and-seek? |
Yes
No
|
| 5. Does your child ever pretend, for example, to talk on the phone or take care of dolls, or pretend other things? |
Yes
No
|
| 6. Does your child ever use his/her index finger to point, to indicate interest in something? |
Yes
No
|
| 7. Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them? |
Yes
No
|
| 8. Does your child ever bring objects over to you (parent) to show you something? |
Yes
No
|
| 9. Does your child look you in the eye for more than a second or two? |
Yes
No
|
| 10. Does your child ever seem oversensitive to noise? (e.g., plugging ears) |
Yes
No
|
| 11. Does your child smile in response to your face or your smile? |
Yes
No
|
| 12. Does your child imitate you? (e.g., you make a face-will your child imitate it?) |
Yes
No
|
| 13. Does your child respond to his/her name when you call? |
Yes
No
|
| 14. If you point at a toy across the room, does your child look at it? |
Yes
No
|
| 15. Does your child walk? |
Yes
No
|
| 16. Does your child make unusual finger movements near his/her face? |
Yes
No
|
| 17. Does you child try to attract your attention to his/her own activity? |
Yes
No
|
| 18. Have you ever wondered if your your child is deaf? |
Yes
No
|
| 19. Does your child understand what people say? |
Yes
No
|
| 20. Does your child sometimes stare at nothing or wander with no purpose? |
Yes
No
|
| 21. Does you child look at your face to check your reaction when faced with something unfamiliar? |
Yes
No
|
| 22. Have you ever filled out this form for this child before? |
Yes
No
|
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