Whole Child Pediatrics

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.

Child's Name Child's DOB 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?

Copyright 1999 Diana Robins, Deborah Fein, & Marianne Barton