In the questions below, please rate your child’s behaviors according to the following scale:
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Ability to engage with you via smiles, eye contact and cooing by 3 months old *
Ability to respond to sounds and laugh by 6 months old *
Ability to control head and neck movements while sitting by 6 months old *
Ability to crawl by 8 months old *
Ability to pull him/herself up to a standing position by 9 months old *
Ability to say 1-3 words with purpose by 1 years old (ex. wave "bye,bye" or say mama, dada) *
Ability to speak in phrases by 18 months old *
Ability to sound out letters by 3 years old *
Do you find that your child has difficulty jumping, climbing or running? *
Does your child have difficulty holding onto pencils or other objects tightly? *
Does your child turn one eye in or out at any time? *
Does your child have difficulty tolerating normal sounds, light, grooming activities, textures in food or clothing? *
Does your child exhibit high levels of aggressiveness or self-injury? *
Does your child have trouble showing empathy to pain caused to oneself or another? *
Does your child have an obsession with certain toys, food, places or odors? *
Does your child frequently lose his/her place while reading, or does he/she need a marker to keep place while reading? *
Does your child make frequent errors in writing text (reversing or omiting letters/words/numbers)? *
Does your child have difficulty pronouncing words or is his/her speech hard to understand? *
Does your child have difficulty understanding stories or directions that he/she has been told? (Ex. understands something else to have been said or misses words) *
Does your child have difficulty finding the words to express thoughts? *
How would you rate your child's self-esteem? *
Does your child show signs of anxiety? (restlessness, trouble sleeping, muscle tension or biting nails) *
Does your exhibit signs or tics, sounds or other repetitive movements? *
Does your act infantile for his/her age? *
Does your child have problems following simple instructions? *
Does your child have difficulty with memorization? *
Is your child behind or struggle in the subject of math? *
Is your child behind or struggle in the subject of reading? *
Does your child have a hard time demonstrating knowledge in exams? *
Does your child struggle with paying attention, concentration or hyperactivity? *