DEVELOPMENTAL CHECKLIST

Play AbilitiesN S F BehaviorDifficulty engaging in pretend play.Wanders around aimlessly without focused exp loration or purposeful play.Breaks toys and other things destructively.Difficulty amusing self for more extended periods of time.Engages in repetitive play for long periods of time.Upset when play routine is interrupted.Prefers to play more with objects than with people.Hurts self or others (e.g. head banging, biting, pinching).Eye contact is fleeting or absent.Comments:Fine Motor SkillsN S F BehaviorDifficulty manipulating small objects.Difficulty dressing, fastening clothes.Difficulty writing or coloring.Difficulty distinguishing right/left.Difficulty cutting with scissors.Developmental MilestonesAgeMetNotYetCrawl.Walk alone.MilestoneSpeak first word(s).Put 2 words together.Speak in simple sentences.Feed self independently.Potty trained.AgeMetNotYetMilestoneUsed gestures – pointing, noddingRide a tricycle.Run well.Hop on one foot.Dress self totally.Tie shoes.Skip.Person(s) filling out this form:Date:Intake attended by:Date:3