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.
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 does not follow an object with her eyes or turn towards sounds
My child does not respond (smile, eye contact) to adult interaction or shows limited interest in others
My child has difficulty holding an object in his hand
My child does not use sounds to get my attention or vocalize when excited/upset
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 has difficulty with walking
My child does not point to objects/pictures or use a pincer grasp
My child has difficulty using both hands together during play
My child doesn’t repeat sounds/gestures when laughed at
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 scribbling or drawing horizontal/vertical lines or stringing beads
My child has difficulty participating in simple pretend play
My child has difficulty separating from me in familiar surroundings
My child is unable to feed self with fingers, utensils or is not eating most adult table foods
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 not using 2 word sentences, or is not speaking at least 50 words
My child does not know the function of common household objects or is unable to understand simple instructions
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 stand on 1 leg, hop on 1 leg, or pump a swing
My child has difficulty drawing a circle, cutting on a line, or folding paper
My child has difficulty with complex pretend play, cooperating with peers, taking turns or sharing with others
My child has difficulty attending to tasks, transitioning between tasks, or tolerating changes in routine
My child is unable to dress self or manage fasteners (snaps, buttons, zipper)
My child is not using sentences of more than 3 words or discussing daily activities and experiences
My child is not using “me” and “you” correctly or understanding 2 part commands with prepositions
5.Age of my child:
6.Name and PHONE NUMBER OR EMAIL of person completing this form (note: you will only be contacted regarding the results of this survey):
7.When is the best time to reach you to discuss the results of this checklist?