Yes
No
E-mail Address
* must provide value
Male Female
Baby's Date of Birth
* must provide value
Y-M-D
Baby's current age in years
View equation Please correct your baby's date of birth if their age is incorrect.
Has your child lost any skills (movement, language, etc...) that they once had?
Yes
No
Please describe the lost skills, and when this occurred.
Has your baby been diagnosed with any of the following:
Deaf or moderate-to-severe hearing impaired
Autism Spectrum Disorder
Pervasive Developmental Disorder, Not Otherwise Specified
Cognitive delay
Speech or language delay
Motor delay
Developmental delay
Social-emotional delay
Adaptive-behavior delay
Other
Deaf or moderate-to-severe hearing impaired
Autism Spectrum Disorder
Pervasive Developmental Disorder, Not Otherwise Specified
Cognitive delay
Speech or language delay
Motor delay
Developmental delay
Social-emotional delay
Adaptive-behavior delay
Other
In which language domain did your child receive a diagnosis?
Speech
Expressive Language
Receptive Language
Speech
Expressive Language
Receptive Language
Has your child's sibling been diagnosed with any of the following?
Deaf or moderate-to-severe hearing impaired
Autism Spectrum Disorder
Pervasive Developmental Disorder, Not Otherwise Specified
Cognitive delay
Speech or language delay
Motor delay
Developmental delay
Social-emotional delay
Adaptive-behavior delay
Attention Deficit Hyperactivity Disorder (ADHD)
Other
Deaf or moderate-to-severe hearing impaired
Autism Spectrum Disorder
Pervasive Developmental Disorder, Not Otherwise Specified
Cognitive delay
Speech or language delay
Motor delay
Developmental delay
Social-emotional delay
Adaptive-behavior delay
Attention Deficit Hyperactivity Disorder (ADHD)
Other
Has your baby had any of the following diagnoses or procedures?
Seizure
Stroke
Intracranial hemorrhage
Hypoxic ischemic encephalopathy requiring cooling
Extracorporeal membrane oxygenation (ECMO)
Perinatal asphyxia
Acid reflux
Infant respiratory distress syndrome
Jaundice
Colic
Down syndrome
Failure to thrive
Tic disorder
Head injury, brain tumor, cortical dysplasia
Cardiac disorder
Recurrent ear infections
Surgery requiring general anesthesia
Re-hospitalization following initial hospital discharge
Small for gestational age
Low birthweight
Brain damage
Cerebral palsy
Cochlear implant
Other (please specify)
Seizure
Stroke
Intracranial hemorrhage
Hypoxic ischemic encephalopathy requiring cooling
Extracorporeal membrane oxygenation (ECMO)
Perinatal asphyxia
Acid reflux
Infant respiratory distress syndrome
Jaundice
Colic
Down syndrome
Failure to thrive
Tic disorder
Head injury, brain tumor, cortical dysplasia
Cardiac disorder
Recurrent ear infections
Surgery requiring general anesthesia
Re-hospitalization following initial hospital discharge
Small for gestational age
Low birthweight
Brain damage
Cerebral palsy
Cochlear implant
Other (please specify)
Check the milestones your child has reached by his or her 1st birthday. Take this with you and talk with your child's doctor at every visit about the milestones your child has reached and what to expect next.
Is shy or nervous with strangers
* must provide value
Yes
No
Cries when mom or dad leaves
* must provide value
Yes
No
Has favorite things and people
* must provide value
Yes
No
Shows fear in some situations
* must provide value
Yes
No
Hands you a book when he wants to hear a story
* must provide value
Yes
No
Repeats sounds or actions to get attention
* must provide value
Yes
No
Puts out arm or leg to help with dressing
* must provide value
Yes
No
Plays games such as "peek-a-boo" and "pat-a-cake"
* must provide value
Yes
No
Responds to simple spoken requests
* must provide value
Yes
No
Uses simple gestures, like shaking head "no" or waving "bye-bye"
* must provide value
Yes
No
Makes sounds with changes in tone (sounds more like speech)
* must provide value
Yes
No
Says "mama" and "dada" and exclamations like "uh-oh!"
* must provide value
Yes
No
Tries to say words you say
* must provide value
Yes
No
Cognitive (learning, thinking, problem-solving)
* must provide value
Yes
No
Explores things in different ways, like shaking, banging, throwing
* must provide value
Yes
No
Finds hidden things easily
* must provide value
Yes
No
Looks at the right picture or thing when it's named
* must provide value
Yes
No
Copies gestures
* must provide value
Yes
No
Starts to use things correctly; for example, drinks from a cup, brushes hair
* must provide value
Yes
No
Bangs two things together
* must provide value
Yes
No
Puts things in a container, takes things out of a container
* must provide value
Yes
No
Lets things go without help
* must provide value
Yes
No
Pokes with index (pointer) finger
* must provide value
Yes
No
Follows simple directions like "pick up the toy"
* must provide value
Yes
No
Gets to a sitting position without help
* must provide value
Yes
No
Pulls up to stand, walks holding on to furniture ("cruising")
* must provide value
Yes
No
May take a few steps without holding on
* must provide value
Yes
No
May stand alone
* must provide value
Yes
No
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