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.

	Walks alone.
	Pulls toys behind him while walking.
	Carries large toy or several toys while walking.
	Begins to run stiffly.
	Walks into ball.
	Climbs onto and down from furniture unsupported.
	Walks up and down stairs holding on to support.
	Scribbles spontaneously.
	Turns over container to pour out contents.
	Builds tower of four blocks or more.
	Completes simple knobbed wooden puzzles of 3 to 4 pieces.
	Says "no" with meaning.
	Follows simple, one-step instructions.
	Says several single words.
	Recognizes names of familiar people, objects, and body parts.
	Points to object or picture when it's named for them.

	Repeats words overheard in conversations.
	Uses two-word sentences.
	Will listen to short story book with pictures.
	Identifies one body part.
	Begins to sort shapes and colors.
	Begins make-believe play.
	Starts to feed self with spoon, with some spilling.
	Likes to play with food when eating.
	Can put shoes on with help.
	Can open doors with knobs.
	Can drink from open cup with no assistance, with some spilling.
	Imitates behavior of others, especially adults and older children.
	Enjoys playing alongside other children.
	Likes to do things for himself.
	Begins to show defiant behavior (the "no" stage)

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)

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