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Childs Record 1
(Ages 0 month to 3 years)
Socio demographic Profile: Indicate the complete socio demographic profile of the
child.
Childs Name:
Sex:
Address:
Childs handedness:
Chronological Age:
____ Right
____ Left
____ no
If yes, write the name of the childs school / learning center / day care:
Fathers Name:
Age:
Fathers Occupation:
Mothers Name:
Age:
Mothers Occupation:
B. Optional Starting Point for Children Ages 1year and 1month to 3 years
_____ 5. Uses all five fingers to get food / toys placed on flat surface
_____ 6. Picks up objects with thumb and index finger
_____ 7. Pulls toys with string
_____ 8. Displays a definite hand preference
_____ 9. Grasps and transfers objects from hand to hand
_____ 10. Pushes or pulls a large object
_____ 11. Puts small objects in / out of container
_____ 12. Holds crayon with all the fingers of his hand as though making a fist (i.e.,
palmar grasp)
_____ 13. Unscrews lid of container or unwraps food
_____ 14. Scribbles spontaneously
TOTAL SCORE: __________
SELF HELP DOMAIN
A.
B. Optional Starting Point for Children Ages 1year and 1month to 3 years
_____ 4. Holds bottle all by himself
_____ 5. Feeds self with finger food (e.g., biscuits, bread, etc.) using fingers
_____ 6. Helps hold a cup for drinking
_____ 7. Feeds self using fingers to eat rice / viands with spillage
_____ 8. Drinks from a cup without help
_____ 9. Feeds self using spoon with spillage
_____ 10. Gets a drink for himself without any help
TOTAL SCORE: __________
RECEPTIVE LANGUAGE DOMAIN
A.
B. Optional Starting Point for Children Ages 1year and 1month to 3 years
_____ 6. Turns head when called by name
_____ 7. Understands no
_____ 8. Imitates adults playful sounds like coughing or lip smacking
_____ 9. Follows one-step command (e.g., give) when gestures are used
_____ 10. Follows one-step command without need for gestures
_____ 11. Points to a family member when asked to do so
_____ 12. points to 5 body parts of his when asked to do so
_____ 13. Points to five named pictured objects when asked to do so
_____ 14. Follows one-step instructions that include simple prepositions (e.g., in,
on, under)
_____ 15. Follows 2-step instructions that include simple prepositions
TOTAL SCORE: __________
_____ 4. Infant changes face when he does not like the taste of his food
_____ 5. Infant explores and manipulates objects by biting, holding and looking at
them
_____ 6. Infant shakes toy deliberately to make this sound
_____ 7. Infant eventually gets used to irritating or bothersome familiar sounds
_____ 8. Infant reacts to cloth placed over his face
B. Optional Starting Point for Children Ages 1year and 1month to 3 years
_____ 9. Looks in the direction of a fallen object
_____ 10. Displays for a preference for certain objects by reaching for these more
readily than others
_____ 11. Pushes the ball to make it roll
_____ 12. Repeatedly drops or throws objects
_____ 13. Looks for partially hidden object
_____ 14. Imitates behavior just seen a few minutes earlier
_____ 15. Offers an object but may not release it
_____ 16. Looks for completely hidden object
_____ 17. Exhibits simple pretend play
_____ 18. Matches objects
SOCIO-EMOTIONAL DEVELOPMENT
A. Infant Section (Ages 0 month to 1.0 year)
_____ 1. Infant stops crying when mother picks him
_____ 2. Infant smiles in response to the caregiver
_____ 3. Infant reacts to familiar situations like bathing or feeding
_____ 4. Infant lifts arms to greet familiar people
B. Optional Starting Point for Children Ages 1year and 1month to 3 years
_____ 5. Cries when caregiver leaves
_____ 6. Enjoys watching activities of nearby people or animals
_____ 7. Smiles playfully at mirror image
_____ 8. Friendly with strangers but initially may show slight anxiety or shyness
_____ 9. Plays alone but likes to be near familiar adults or brothers or sisters
_____ 10. Laughs or squeals aloud in play
_____ 11. Plays peek-a-boo
___________________________________
EXAMINER