UPDOX - PATIENT PORTAL

Patients Name * Patients DOB *

Movement and Physical Development

Climbs well Runs easily Pedals a tricycle (3-wheel bike) Walks up and down stairs, one foot on each step Can stack 4-5 blocks

Social and Emotional

Copies adults and friends Shows affection for friends without prompting Takes turns in games Shows concern for crying friends Understands the idea of "mine" and "his" or "hers" Shows a wide range of emotions Separates easily from mom and dad May get upset with major changes in routine Dresses and undresses self

Language/ Communications

Follows instructions with 1 or 2 steps Can name most familiar things Understands words like "in" "on" and "under" Says first name, age, and sex Can name a friend Says words like "i" "we" "me" and "you" and some plurals (cars,dogs,cats) Talks well enough for strangers to understand most of the time Carries on a conversation using 2 to 3 sentences

Cognitive (learning, thinking, problem-solving)

Can work toys with levers, buttons, and moving parts Plays make believe with dolls, animals, and people Can do a puzzle with 3 or 4 pieces Copies a circle with a pencil or crayon Turns book pages one at a time Builds towers with more than 6 blocks Screws and unscrews jar lids or turns door handle Electronic signature of parent/ guardian * Name and DOB of Guardian completing form * Today's date *