PLEASE FILL OUT THIS FORM SO WE CAN PREPARE FOR YOUR APPOINTMENTIF YOUR CHILD IS 18-24 MONTHS 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) Likes to hand things to others as play May have temper tantrums May be afraid of strangers Shows affection to familiar people Plays simple pretend, such as feeding a doll May cling to caregivers in new situations Points to show others something interesting Explores alone but with parent close by Select AllSelect all that applyLanguage/Communication(Required) Says several single words Says and shakes head “no” Points to show someone what he wants Select AllSelect all that applyCognitive (learning, thinking, problem-solving)(Required) Knows what ordinary things are for; for example, telephone, brush, spoon Points to get the attention of others Shows interest in a doll or stuffed animal by pretending to feed Points to one body part Scribbles on his own Can follow 1-step verbal commands without any gestures; for example, sits when you say “sit down” Select AllSelect all that applyMovement/Physical Development(Required) Walks alone May walk up steps and run Pulls toys while walking Can help undress herself Drinks from a cup Eats with a spoon Select AllSelect all that applyPlease check if your child:(Required) Doesn’t point to show things to others Can’t walk Doesn’t know what familiar things are for Doesn’t copy others Doesn’t gain new words Doesn’t have at least 6 words Doesn’t notice or mind when a caregiver leaves or returns Loses skills he once had Select AllSelect all that applyAre there any other concerns you would like to discuss?
