Illini Pediatrics LLC, DBA Ideal Pediatrics

18 month Developmental

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

At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your child more than one time. If possible, try the activities when you chid is cooperative. If you child can do the activity but refuses, mark "yes" for the item.

Communication

1. When your child wants something, does she tell you by pointing to it? 2. When you ask your child to, does he go into another room and find a familiar toy or object? (You might ask, "Where is your ball?" or say, "Bring me your coat," or "Go get your blanket.") 3. Does your child say eight or more words in addition to "Mama" and "Dada"? 4. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as "Mama eat," "Daddy play," "Go home,"or "What's this?" does your child say both words back to you? (Mark "yes" even if her words are difficult to understand.) 5. Without your showing him, does your child point to the correct picture when you say, "Show me the kitty," or ask, "Where is the dog?" (He needs to identify only one picture correctly.) 6. Does your child say two or three words that represent different ideas together, such as "See dog," "Mommy come home," or "Kitty gone"? (Don't count word combinations that express one idea, such as "bye-bye," "all gone," and "What's that?") Please give an example of your child's word combinations: Example of word combinations:

Gross Motor

1. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support? 2. Does your child move around by walking, rather than by crawling on her hands and knees? 3. Does your child walk well and seldom fall? 4. Does your child climb on an object such as a chair to reach something he wants (for example, to get a toy on a counter or to "help" you in the kitchen)? 5. Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.) 6. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (If your child already kicks a ball, mark "yes" for this item.)

Fine Motor

1. Dose your child throw a small ball with a forward arm motion? (If he simply drops the ball, mark "not yet" for this item.) 2. Does your child stack a small block or toy on top of another one? (You could also use spools of tread, small boxes, or toys that are about 1 inch in size.) 3. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw? 4. Does your child stack three small blocks or toys on top of each other by himself? 5. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.) 6. Does your child get a spoon into her mouth right side up so that the food usually doesn't spill?

Problem Solving

1. Does your child drop several small toys, one after another, into a container like a bowl or box. ( You may show him how to do it.) 2. After you have shown your child how, does she try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool? 3. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle over to dump it out? (You may show him how.) (You can use a soda-pop bottle or a baby bottle.) 4. Without showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)? 5. After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark "not yet" if your child scribbles back and forth.) 6. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump out the crumb or Cheerio? (Do not show him how.)

Personal-Social

1. While looking at herself in the mirror, does your child offer a toy to her own image? 2. Does your child play with a doll or stuffed animal by hugging it? 3. Does your child get your attention or try to show you something by pulling on your hand or clothes? 4. Does your child come to you when he needs help, such as with winding up a toy or unscrewing a lid from a jar? 5. Does your child drink from a cup or glass, putting it down again with little spilling? 6. Does your child copy the activities you do, such as wipe up spills, sweep, shave, or comb hair?

Overall

1. Do you think your child hears well? If no, explain: 2. Do you think your child talks like other toddlers his age? If no, explain: 3. Can you understand most of what your child says? If no, explain: 4. Do you think your child walks, runs, and climbs like other toddlers her age? If no, explain: 5. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain: 6. Do you have concerns about your child's vision? If yes, explain: 7. Has your child had any medical problems in the last several months? If yes, explain: 8. Do you have any concerns about your child's behavior? If yes, explain: 9. Does anything about your child worry you? If yes, explain:

MCHAT- toddler autism screening

Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g., you've seen it once or twice), please answer as if the child does not do it.

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

Bright Futures- how is your child doing?

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

Your Child and Family Your Child's Behavior Talking and Hearing Toilet Training Safety Have any of your child's relatives developed new medical problems since your last visit? Do you have concerns about how your child hears? Do you have any concerns about how your child speaks? Do you have concerns about how your child sees? Does your child hold objects close when trying to focus? Do your child's eyes appear unusual or seem to cross, drift, or be lazy? Do your child's eyelids droop or does one eyelid tend to close? Have your child's eyes ever been injured? Do you ever struggle to put food on the table? Does your child's diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? Does your child have a dentist? Does your child's primary water source contain fluoride? Does your child have any special health care needs? If yes, please describe: Have there been any major changes in your family lately? Does your child live with anyone who uses tobacco or spend time in any place where people smoke? Check off each of the tasks that your child 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? **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? Between 12 & 72 months, and has never received a blood lead test? Live in an area of the state at high-risk for lead poisoning? (list published annually)

TB Risk Assessment

1. Does the child have any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss or fatigue) or an abnormal chest X-ray? If yes, what symptom 2. In the last 2 years, has the child lived with or spent time with someone who has been sick with TB? 3. Was the child born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East? If yes, in what country was the child born: 4. Has the child lived or traveled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East for more than one month? If yes, in what country did the child travel to: 5. Have any member of the child's household come to the United States from another country? If yes, name of country: 6. Is the child exposed to a person who: 7. Is the child/teen in jail or ever been in jail? 8. does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression? If yes, name of disease or medication:

If yes, to any of the above, the child has and increased risk of TB infection and should have a TST/IGRA. All children with a positive TST/IGRA result must have a medical evaluation, including a chest X-ray. Treatment for latent TB infection should be initiated if the chest X-ray is normal and there are no signs of active TB. If testing was done, please attach or enter results on next page.