M-CHAT

Child's Name*

Does your child enjoy being swung, bounced on your knee. etc?

Yes
No

Does your child take an interest in other children?

Yes
No

Does your child like climbing on things, such as stairs?

Yes
No

Does your child enjoy playing peek-a-boo/hide-and-seek?

Yes
No

Does your child ever pretend, for example to talk on the phone or take care of a doll or pretend other things?

Yes
No

Does your child ever use his/her index finger to point, to ask for something?

Yes
No

Does your child ever use his/her index finger to point, to indicate interest in something?

Yes
No

Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them?

Yes
No

Does your child ever bring objects over to you (parent) to show you something?

Yes
No

Does your child look you in the eye for more than a second or two?

Yes
No

Does your child seem oversensitive to noise (e.g. plugging cars)?

Yes
No

Does your child smile in response to your face or your smile?

Yes
No

Does your child imitate you? (e.g., you make a face will your child imitate it?)

Yes
No

Does your child respond to his/her name when you call?

Yes
No

If you point at a toy across the room, does your child look at it?

Yes
No

Does your child walk?

Yes
No

Does your child look at things you are looking at?

Yes
No

Does your child make unusual finger movements near his/her face?

Yes
No

Does your child try to attract your attention to his/her own activity?

Yes
No

Have you ever wondered if your child is deaf?

Yes
No

Does your child understand what people say?

Yes
No

Does your child sometimes stare at nothing or wander 'with no purpose?

Yes
No

Does your child look at your face to check your reaction when faced with something unfamiliar?

Yes
No

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Phone: (503) 713-5330

Fax: (503) 334-1256

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