Screening Survey: Under 5 Years

Screening Checklist 5 yrs. and Under

Read each item below and respond 'yes' for those items which describe your child.

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* 1. If your child is 6 months- 1 year of age, please respond to the questions below. If your child is older and displayed the behaviors listed below during this age range, select 'Past'

	Yes	Past
My child has not achieved age appropriate gross motor milestones (rolling, crawling, etc)	My child has not achieved age appropriate gross motor milestones (rolling, crawling, etc) Yes	My child has not achieved age appropriate gross motor milestones (rolling, crawling, etc) Past
My child does not follow an object with her eyes or turn towards sounds	My child does not follow an object with her eyes or turn towards sounds Yes	My child does not follow an object with her eyes or turn towards sounds Past
My child does not respond (smile, eye contact) to adult interaction or shows limited interest in others	My child does not respond (smile, eye contact) to adult interaction or shows limited interest in others Yes	My child does not respond (smile, eye contact) to adult interaction or shows limited interest in others Past
My child has difficulty holding an object in his hand	My child has difficulty holding an object in his hand Yes	My child has difficulty holding an object in his hand Past
My child does not use sounds to get my attention or vocalize when excited/upset	My child does not use sounds to get my attention or vocalize when excited/upset Yes	My child does not use sounds to get my attention or vocalize when excited/upset Past

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* 2. For children 1-2 years, please respond to the questions below. If your child is older and displayed the behaviors listed below during this age range, select 'Past'

	Yes	Past
My child does not search for objects that are hidden	My child does not search for objects that are hidden Yes	My child does not search for objects that are hidden Past
My child has difficulty with walking	My child has difficulty with walking Yes	My child has difficulty with walking Past
My child does not point to objects/pictures or use a pincer grasp	My child does not point to objects/pictures or use a pincer grasp Yes	My child does not point to objects/pictures or use a pincer grasp Past
My child has difficulty using both hands together during play	My child has difficulty using both hands together during play Yes	My child has difficulty using both hands together during play Past
My child doesn’t repeat sounds/gestures when laughed at	My child doesn’t repeat sounds/gestures when laughed at Yes	My child doesn’t repeat sounds/gestures when laughed at Past

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* 3. If your child is 2-3 years of age, please respond to the questions below. If your child is older and displayed the behaviors listed below during this age range, select 'Past'

	Yes	Past
My child has difficulty matching objects to pictures or finding details in picture books	My child has difficulty matching objects to pictures or finding details in picture books Yes	My child has difficulty matching objects to pictures or finding details in picture books Past
My child has difficulty scribbling or drawing horizontal/vertical lines or stringing beads	My child has difficulty scribbling or drawing horizontal/vertical lines or stringing beads Yes	My child has difficulty scribbling or drawing horizontal/vertical lines or stringing beads Past
My child has difficulty participating in simple pretend play	My child has difficulty participating in simple pretend play Yes	My child has difficulty participating in simple pretend play Past
My child has difficulty separating from me in familiar surroundings	My child has difficulty separating from me in familiar surroundings Yes	My child has difficulty separating from me in familiar surroundings Past
My child is unable to feed self with fingers, utensils or is not eating most adult table foods	My child is unable to feed self with fingers, utensils or is not eating most adult table foods Yes	My child is unable to feed self with fingers, utensils or is not eating most adult table foods Past
My child is unable to run well, stand on 1 foot, jump with 2 feet together, or go up/down stairs alone	My child is unable to run well, stand on 1 foot, jump with 2 feet together, or go up/down stairs alone Yes	My child is unable to run well, stand on 1 foot, jump with 2 feet together, or go up/down stairs alone Past
My child is not using 2 word sentences, or is not speaking at least 50 words	My child is not using 2 word sentences, or is not speaking at least 50 words Yes	My child is not using 2 word sentences, or is not speaking at least 50 words Past
My child does not know the function of common household objects or is unable to understand simple instructions	My child does not know the function of common household objects or is unable to understand simple instructions Yes	My child does not know the function of common household objects or is unable to understand simple instructions Past

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* 4. For children 4-5 years old, please respond to the questions below.

	Yes	N/A
My child is unable to throw a ball overhand or catch a ball with both hands	My child is unable to throw a ball overhand or catch a ball with both hands Yes	My child is unable to throw a ball overhand or catch a ball with both hands N/A
My child is unable to stand on 1 leg, hop on 1 leg, or pump a swing	My child is unable to stand on 1 leg, hop on 1 leg, or pump a swing Yes	My child is unable to stand on 1 leg, hop on 1 leg, or pump a swing N/A
My child has difficulty drawing a circle, cutting on a line, or folding paper	My child has difficulty drawing a circle, cutting on a line, or folding paper Yes	My child has difficulty drawing a circle, cutting on a line, or folding paper N/A
My child has difficulty with complex pretend play, cooperating with peers, taking turns or sharing with others	My child has difficulty with complex pretend play, cooperating with peers, taking turns or sharing with others Yes	My child has difficulty with complex pretend play, cooperating with peers, taking turns or sharing with others N/A
My child has difficulty attending to tasks, transitioning between tasks, or tolerating changes in routine	My child has difficulty attending to tasks, transitioning between tasks, or tolerating changes in routine Yes	My child has difficulty attending to tasks, transitioning between tasks, or tolerating changes in routine N/A
My child is unable to dress self or manage fasteners (snaps, buttons, zipper)	My child is unable to dress self or manage fasteners (snaps, buttons, zipper) Yes	My child is unable to dress self or manage fasteners (snaps, buttons, zipper) N/A
My child is not using sentences of more than 3 words or discussing daily activities and experiences	My child is not using sentences of more than 3 words or discussing daily activities and experiences Yes	My child is not using sentences of more than 3 words or discussing daily activities and experiences N/A
My child is not using “me” and “you” correctly or understanding 2 part commands with prepositions	My child is not using “me” and “you” correctly or understanding 2 part commands with prepositions Yes	My child is not using “me” and “you” correctly or understanding 2 part commands with prepositions N/A

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* 5. Age of my child:

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* 6. Name and PHONE NUMBER OR EMAIL of person completing this form (note: you will only be contacted regarding the results of this survey):

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* 7. When is the best time to reach you to discuss the results of this checklist?