9 month old Well Child Visit Questionnaires Patient Information Child's Name * First Name Last Name Child's Birthday * MM DD YYYY Name of Parent filling out form * First Name Last Name Today's Date * MM DD YYYY Pediatric Evaluation Developmental Survey (PEDS) Do you have any concerns about the way your child talks or makes speech sounds? * YES NO A little Comments: Do you have any concerns about how your child understands what you say? * YES NO A little Comments: Do you have any concerns about the way your child uses his/her hands or fingers to do things? * YES NO A little Comments: Do you have any concerns about the way your child uses his/her legs? * YES NO A little Comments: Do you have any concerns about the way your child behaves? * YES NO A little Comments Do you have any concerns about how your child interacts with others? * YES NO A little Comments: Do you have any concerns about how your child is learning new things to do things for him/herself? * YES NO A little Comments: Do you have any concerns about how your child is learning preschool or school skills? * YES NO A little Comments: Please list any other concerns you have about your chlid's learning, development, or behavior. Modified Checklist for Autism in Toddlers (MCHAT) Screens for autistic features in a child. Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no. Please circle yes or no for every question. Thank you very much. 1. If you point at something across the room, does your child look at it? * (FOR EXAMPLE, if you point at a toy, does your child look at the toy?) YES NO 2. Have you ever wondered if your child might be deaf? * YES NO 3. Does your child play pretend or make-believe? * FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal? YES NO 4. Does your child like climbing on things? * FOR EXAMPLE, furniture, playground equipment, or stairs? YES NO 5. Does your child make unusual finger movements near his or her eyes? * FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes? YES NO 6. Does your child point with one finger to ask for something or to get help? * FOR EXAMPLE, pointing to a snack or toy that is out of reach YES NO 7. Does your child point with one finger to show you something interesting? * FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road? YES NO 8. Is your child interested in other children? * FOR EXAMPLE, does your child watch other children, smile at them, or go to them? YES NO 9. Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share? * FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck. YES NO 10. Does your child respond when you call his or her name? ( * FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name? YES NO 11. When you smile at your child, does he or she smile back at you? * YES NO 12. Does your child get upset by everyday noises? * FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music? YES NO 13. Does your child walk? * YES NO 14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her? * YES NO 15. Does your child try to copy what you do? * FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do YES NO 16. If you turn your head to look at something, does your child look around to see what you are looking at? * YES NO 17. Does your child try to get you to watch him or her? * FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”? YES NO 18. Does your child understand when you tell him or her to do something? * FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair” or “bring me the blanket”? YES NO 19. If something new happens, does your child look at your face to see how you feel about it? * FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face? YES NO Does your child like movement activities? * FOR EXAMPLE, being swung or bounced on your knee YES NO Lead Screening Questionnaire To screen if your child is at risk for lead exposure. 1. Does your child have QUEST insurance? * YES NO Don't know 2. Does your child live in any of the zip codes below? * 96786 96792 96797 96813 96815 96816 96817 96819 96822 96826 96848 96854 96857 YES NO Don't know 3. Does your child have a brother, sister, or playmate who was exposed to lead? * YES KNOW Don't know 4. Does your child often chew dirt, paint chips, or things that are not food? * YES KNOW Dont' know 5. Was your child born outside the United States or did your child come from another country within the past 1 year? * YES KNOW Dont' know 6. Are you concerned that your child may be exposed to lead? * YES NO Dont' know 7. Does your child live in a home or receive child care in a building built before 1978? * YES NO Dont' know 8. Does anyone who spends time with your child have a job or hobby in: * - Making fishing sinkers / fishing activities / boat repair - Remodeling / repainting / fixing the home - Automotive repair / car batteries - Making ceramics or pottery using lead glaze - Painting / electrical / plumbing / soldering / welding YES NO Dont' know 9. Does your family cook and/or serve food using ceramic dishes or pottery made in other countries that are handmade, brightly decorated, or old? * YES NO Dont' know 10. Does your family have a rainwater catchment system? * YES NO Don't know Thank you! FORMS SUBMITTED.
