Royal Oak Pediatrics

M - CHAT

INSTRUCTIONS:

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.

			18 Months		24 Months
	1.	Does your child enjoy being swung, bounced on your knee, etc.?	Yes	No	Yes	No
*	2.	Does your child take an interest in other children?	Yes	No	Yes	No
	3.	Does your child like climbing on things, such as stairs?	Yes	No	Yes	No
	4.	Does your child enjoy playing peek-a-boo/hide-and-seek?	Yes	No	Yes	No
	5.	Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things?	Yes	No	Yes	No
	6.	Does your child ever use his or her index finger to point, to ask?	Yes	No	Yes	No
*	7.	Does your child ever use his/her index finger to point, to indicate interest in something?	Yes	No	Yes	No
	8.	Can your child play properly with toys (e.g., cars or bricks) without just mouthing, fiddling or dropping them?	Yes	No	Yes	No
*	9.	Does your child ever bring objects over to you (parent) to show you something?	Yes	No	Yes	No
	10.	Does your child look you ni the eye for more than a second or two?	Yes	No	Yes	No
	11.	Does your child ever seem oversensitive to noise (e.g., plugging ears)?	Yes	No	Yes	No
	12.	Does your child smile in response to your face or smile?	Yes	No	Yes	No
*	13.	Does your child imitate you (e.g., you make a face - will your child imitate it)?	Yes	No	Yes	No
*	14.	Does your child respond to his/her name when you call?	Yes	No	Yes	No
*	15.	If you point at a toy across the room, does your child look at it?	Yes	No	Yes	No
	16.	Does your child walk?	Yes	No	Yes	No
	17.	Does your child look at things you are looking at?	Yes	No	Yes	No
	18.	Does your child make unusual finger movements near his/her face?	Yes	No	Yes	No
	19.	Does your child try to attract your attention to his/her own activity?	Yes	No	Yes	No
	20.	Have you ever wondered if your child is deaf?	Yes	No	Yes	No
	21.	Does your child understand what people say?	Yes	No	Yes	No
	22.	Does your child sometimes start at nothing or wander with no purpose?	Yes	No	Yes	No
	23.	Does your child look at your face to check your reaction when faced with something unfamiliar?	Yes	No	Yes	No

	Have you ever filled out this form for this child before		Yes	No