Illini Pediatrics LLC, DBA Ideal Pediatrics

9 month Developmental

Child's Full Name: * Child's Date of Birth Do you have an appointment? *

Please read each questions carefully and check the box that best describes your child's behavior.

Communication

1. Does your baby make sounds like "da", "ga", "ka" and "ba"? 2. If you copy the sounds that your baby makes, does your baby repeat the same sounds back to you? 3. Does your baby make two similar sounds like "ba-ba," "da-da," or "ga-ga"? (The sounds don't need to mean anything.) 4. If you ask your baby to, does he play at least one nursery game even if you don't show her the game yourself? (such as "bye-bye", "peekaboo", "clap your hands", "SoBig")? 5. Does your baby follow one simple command such as "Come here", "Give it to me" or "Put it back", without using gestures ? 6. Does your baby say three words, such as "Mama", "Dada" and "Baba"? (A "word" is a sound or sounds your baby says consistently to mean someone or something)

Gross Motor

1. If you hold both hands just to balance, does she support her own weight while standing? 2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support? 3. When you stand your baby next to furniture or the crib rail, does she hold on without leaning her chest against the furniture for support? 4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position? 5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)? 6. Does your baby walk beside furniture while holding on with only one hand?

Fine Motor

1. Dose your baby pick up a small toy with only one hand? 2. Does your baby successfully pick up a crumb or Cheerio by using her thumb and all of her finders in a raking motion? (If she already picks up a crumb or Cheerio, mark "yes" for this item) 3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm). 4. After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (the string may be attached to a toy.) 5. Does your baby pick up a crumb or Cheerio with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it. 6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?

Problem Solving

1. Does your baby pass a toy back and forth from one hand to the other? 2. Does your Baby pick up two small toys, one in each hand, and hold onto them for about 1 minute? 3. When holding a toy in his hand, does your baby bang it against another toy of the table? 4. While holding a small toy in each hand, does your baby clap the toys together (like "Pat-a-cake")? 5. Does your baby poke at or try to get a crumb or Cheerio the tis inside a cleat bottle (such as a plastic soda-pop bottle or baby bottle)? 6. After watching you hide a small toy under a piece of paper or cloth, does you baby find it? (Be sure the toy is completely hidden)

Personal-Social

1. While your baby is on her back, does she put her foot in her mouth? 2. Does your baby drink water, juice, or formula from a cup while you hold it? 3. Does your baby feed himself a cracker or a cookie? 4. When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn't let go of it? (If she already lets go of the toy into your hand, mark "yes" for this item.) 5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve? 6. When you hold our your hand and ask for her toy, does your baby let go of it into your hand?

Overall

1. Does your baby use both hands and both legs equally well? If no, explain: 2. When you help your baby stand, are his feet flat on the surface most of the time? If no, explain: 3. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain: 4. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain: 5. Do you have concerns about your baby's vision? If yes, explain: 6. Has your baby had any medical problems in the last several months? If yes, explain: 7. Do you have any concerns about your baby's behavior? If yes, explain: 8. Does anything about your baby worry you? If yes, explain:

Bright Futures- What would you like to talk about today

For us to provide you and your baby with the best possible health care, we would like to know how things are going. Please answer all of the questions. Thank you.

Do you have any concerns, questions, or problems that you would like to discuss today?

We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.

Your Baby and Family Your Changing and Developing Baby Feeding Your Baby Safety

Questions About Your Baby

Have any of your baby's relatives developed new medical problems since your last visit? If yes, please describe: Hearing - Do you have concerns about how your child hears? Do you have concerns about how your child sees? Do your child's eyes appear unusual or seem to cross, drift, or be lazy? Does your child's eyelids droop or does one eyelid tend to close? Have your child's eyes ever been injured? Are cavities a problem for you or anyone else in your family? Does your child sleep with a bottle? Does your child continuously breastfeed through the night? Check off each of the tasks that your baby is able to do

Lead Risk Assessment

Have siblings or playmates with lead poisoning? Live in or regularly visit a house or day care built before 1950? Reside in or visit a house built before 1978 with chipping paint or remodeling within the last 6 months? **Mouth or eat non-food items (pica)? Play in bare soil or reside in a lead smelting area? Reside with an individual that works with or has hobbies using lead? Receive unusual medicines or folk remedies? Live in an area of the state at high-risk for lead poisoning? (list published annually)