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.

	Climbs well.
	Walks down stairs alone, placing both feet on each step.
	Walks up stairs alternating feet with support.
	Swings leg to kick ball.
	Runs easily.
	Pedals tricycle.
	Bends over easily without falling.
	Makes vertical, horizontal, circular strokes with pencil or crayon.
	Turns book pages one at a time.
	Builds a tower of more than 6 blocks.
	Holds a pencil in writing position.
	Screws and unscrews jar lids, nuts and bolts
	Turns rotating handles (door knobs)
	Uses pronouns (I, you, me, we, they)
	Understands most sentences.
	Recognizes and identifies almost all common objects and pictures.
	Shows frustration when not understood by others.
	Understands physical relationships (on, in, under)
	Can say name, age, and whether boy or girl.
	Uses words to communicate wants and needs.

	Knows simple rhymes and songs.
	Strangers can understand most words.
	Makes mechanical toys work.
	Matches an object in hand or room to a picture in a book.
	Plays make-believe with dolls, animals, and people.
	Sorts objects by color.
	Completes puzzles with 3 or 4 pieces.
	Understands concept of "two."
	Sits and listens to stories.
	Knows several parts of the body.
	Can pull pants down with help.
	Helps puts things away.
	Serves self at table with some spilling.
	Uses the word "mine" often.
	Says "no" but will still do what is asked.
	Expresses a wide range of emotions.
	Objects to major changes in routine, but is becoming more compliant.
	Begins to follow simple rules.
	Begins to separate more easily from parents.

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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