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.

	Crawls forward on belly.
	Assumes hand and knee position.
	Gets to a sitting position without assistance.
	Pulls sel up to a standing position at furniture.
	Creeps on hands and knees.
	Gets from sitting to crawling or lying on stomach.
	Walks holding onto furniture.
	Stands momentarily without support.
	May walk two or three steps without support.
	Grasps using thumb and index finger.
	Bangs two one-inch cubes together.
	Pokes with index finger.
	Puts objects into container.
	Takes objects out of container.
	Tries to imitate scribbling.
	Looks at correct picture when image is named.
	Explores objects in many different ways (shaking, banging, throwing, dropping)
	Enjoys looking at pictures in books.
	Imitates gestures.

	Engages in simple games of peek-a-boo, pat-a-cake, or rolling ball to another.
	Finds hidden objects easily.
	Babbles "dada" and "mama."
	Babbles with inflection.
	Says "dada" and "mama" for specific person.
	Responds to "no"" by briefly stopping activity and noticing adult.
	Responds to simple verbal requests, such as "give me."
	Makes simple gestures such as shaking head for "no."
	Uses exclamations such as "oh-oh."
	Finger feeds himself.
	Extends arm or leg to help when being dressed.
	May hold spoon when feeding.
	Shy or anxious with strangers.
	Cries when mother or father leaves.
	Enjoys imitating people in his play.
	Shows specific preferences for certain people and toys.
	Prefers mother and/or regular care provider over all others
	Repeats sounds or gestures for attention.
	May test parents at bed time.

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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