Forms • Lucas County • CivicEngage

Child's Name*

Child's date of birth*

Diagnosis, if any

Full term/Preemie (how many weeks)*

Parent(s) name*

Phone

Email

Zip Code

Today's Date*

Check the box next to the skills your child has mastered.

	Pushes up on extended arms while on tummy
	Pulls to sitting with head drooping backwards
	Sits with support of his hands.
	Sits unsupported for short periods.
	Supports whole weight on legs.
	Grasps feet.
	Transfers objects from hand to hand.
	Uses raking grasp.
	Routinely rolls from stomach to back and back to stomach.
	Plays peek-a-boo.
	Looks for a family member or pet when named.
	Explores toys with hand and mouth.
	Easily follows moving objects with eyes.
	Pulls cloth/blanket when toy is partially hidden under it.

	Grasps objects dangling in front of him.
	Looks for dropped toys.
	Laughs and squeals out loud.
	Can tell when others others are happy/mad by the tone of the voice.
	Responds to sounds by making sounds.
	Responds to spoken bye-bye by waving.
	Uses voice to express joy and displeasure.
	Localizes or turns toward sounds.
	Syllable repetition begins (i.e. mama, dada, baba)
	Enjoys social play.
	Interested in mirror images.
	Can calm down within 1/2 hour when upset.
	Responds to other people's expression of emotion.

Please contact me for follow up:*

Regardless if there is a concern or not

Only if there is a concern.

The best way to reach me is

By phone (listed above)

By email (listed above)

* indicates required fields.