PLEASE FILL OUT THIS FORM SO WE CAN PREPARE FOR YOUR APPOINTMENTIF YOUR CHILD IS 2-3 YEARS OLD Name(Required) First Last Your Child's Name(Required) First Your Child's Birthday MM slash DD slash YYYY Please check what your child is consistently doing:Social and Emotional(Required) Copies others, especially adults and older children Gets excited when with other children Shows defiant behavior (doing what he has been told not to) Plays mainly beside other children, but is beginning to include other children, such as in chase games Select AllSelect all that applyLanguage/Communication(Required) Points to things or pictures when they are named Knows names of familiar people and body parts Says sentences with 2 to 4 words Follows simple instructions Repeats words overheard in conversation Points to things in a book Select AllSelect all that applyCognitive (learning, thinking, problem-solving)(Required) Finds things even when hidden under two or three covers Begins to sort shapes and colors Completes sentences and rhymes in familiar books Plays simple make-believe games Builds towers of 4 or more blocks Might use one hand more than the other Follows two-step instructions such as “Pick up your shoes and put them in the closet.” Names items in a picture book such as a cat, bird, or dog Select AllSelect all that applyMovement/Physical Development(Required) Stands on tiptoe Kicks a ball Begins to run Climbs onto and down from furniture without help Walks up and down stairs holding on Throws ball overhand Makes or copies straight lines and circles Select AllSelect all that applyPlease check if your child:(Required) Doesn’t use 2-word phrases (for example, “drink milk”) Doesn’t know what to do with common things, like a brush, phone, fork, spoon Doesn’t copy actions and words Doesn’t follow simple instructions Doesn’t walk steadily Loses skills she once had Select AllSelect all that applyAre there any other concerns you would like to discuss?
