Child's Name________________________________________________ Date___/___/____
1. Does your child enjoy being swung, bounced on your knee, etc.?
2. Does your child take an interest in other children?
3. Does your child like climbing on things, such as up stairs?
4. Does your child enjoy playing peek-a-boo/hide-and-seek?
5. Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things?
6. Does your child ever use his/her index finger to point to ask for something?
7. Does your child ever use his index finger to point to indicate interest in something?
8. Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them?
9. Does your child ever bring objects over to you (parent) to show you something?
10. Does your child look you in the eye for more than a second or two?
11. Does your child ever seem oversensitive to noise? (e.g. plugging ears)
12. Does your child smile in response to your face or your smile?
13. Does your child imitate you? (e.g. you make a face-will your child imitate it?)
14. Does your child respond to his/her name when you call?
15. If you point at a toy across the room, does your child look at it?
16. Does your child walk?
17. Does your child look at things you are looking at?
18. Does your child make unusual finger movements near his/her face?
19. Does your child try to attract your attention to his/her own activity?
20. Have you ever wondered if your child is deaf?
21. Does your child understand what people say?
22. Does your child sometimes stare at nothing or wander with no purpose?
23. Does your child look at your face to check your reaction when faced with something unfamiliar?
copyright 1999 Diana Robins, Deborah Fein, & Marianne Barton. University of Connecticut, Department of Psychology. Used with permission.
Does your child:
1. Raise his/her arms when you say "come here" or "up"?
2. Know the difference between you and other people?
3. Imitate simple movements such as waving "bye-bye" or clapping?
4. Play simple games such as peek-a-boo or patty cake?
5. Show interest in children other then brothers/sisters?
6. Understand at least 10 words?
7. Use gestures appropriately to indicate "yes," "no," or "I want"?
8. Use common objects for imaginative play, for example, a box may become a house or a car?
9. Imitate sounds made by adults?
10. Say "mama," "dada," or other name for you?
11. Make eye contact with you?
12. Point at things to show them to you such as a picture in a book or a bird in a garden?
13. Point to tings he/she wants that are out of reach, such as juice?
14. Respond by turning or coming when his/her name is called?
15. Look at you and smile in response to your smile and voice without you touching him/her?
16. Demonstrate understanding of the meaning of "no" or "stop"?
17. Look at you and smile when cuddled, touched, or tickled?
18. Give or bring toys to others spontaneously?
19. Make sounds or vocalize to get your attention?
20. Begin to engage in simple pretend play (e.g. pretend to feed a bear, put it to sleep, or take it for a car ride)?
21. Let you know what he/she wants by putting your hand over objects, for example on a box he/she wants you to open?
22. Behave unusually (flap hands, watches fingers move, or spins)?
copyright 2002 Katarzyna Chawarska, Ami Klin, Sara Sparrow, & Fred Volkmar. Used with permission.
Disclaimer: This website is intended to provide information. It is not intended to, nor does it constitute medical or other advice. Readers are warned not to take any action with regard to medical treatment or otherwise based on the information on this website without first consulting a physician.
Copyright © 2004 Coastal Waterman Pediatrics. All rights reserved.
Revised: 05/20/07.