| 1. |
Does your child enjoy being swung, bounced on your knee, etc.? |
YES |
NO |
| 2. |
Does your child take an interest in other children? |
YES |
NO |
| 3. |
Does your child like climbing on things, such as up stairs? |
YES |
NO |
| 4. |
Does your child enjoy playing peek-a-boo/hide-and-seek? |
YES |
NO |
| 5. |
Does your child ever pretend, for example, to talk on the phone or take care of dolls, or pretend other things? |
YES |
NO |
| 6. |
Does your child ever use his/her index finger to point, to ask for something? |
YES |
NO |
| 7. |
Does your child ever use his/her index finger to point, to indicate interest in something? |
YES |
NO |
| 8. |
Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them? |
YES |
NO |
| 9. |
Does your child ever bring objects over to you (parent) to show you something? |
YES |
NO |
| 10. |
Does your child look you in the eye for more than a second or two? |
YES |
NO |
| 11. |
Does your child ever seem oversensitive to noise? (e.g., plugging ears) |
YES |
NO |
| 12. |
Does your child smile in response to your face or your smile? |
YES |
NO |
| 13. |
Does your child imitate you? (e.g., you make a face-will your child imitate it?) |
YES |
NO |
| 14. |
Does your child respond to his/her name when you call? |
YES |
NO |
| 15. |
If you point at a toy across the room, does your child look at it? |
YES |
NO |
| 16. |
Does your child walk? |
YES |
NO |
| 17. |
Does your child look at things you are looking at? |
YES |
NO |
| 18. |
Does your child make unusual finger movements near his/her face? |
YES |
NO |
| 19. |
Does your child try to attract your attention to his/her own activity? |
YES |
NO |
| 20. |
Have you ever wondered if your child is deaf? |
YES |
NO |
| 21. |
Does your child understand what people say? |
YES |
NO |
| 22. |
Does your child sometimes stare at nothing or wander with no purpose? |
YES |
NO |
| 23. |
Does your child look at your face to check your reaction when faced with something unfamiliar? |
YES |
NO |