M-CHAT-R

To be completed at 18 months and 24 months

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Date of Birth:

Please complete this field.

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. 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 or an animal, does your child look at the toy or animal?)

Please select an option.

2. Have you ever wondered if your child might be deaf?

Please select an option.

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?)

Please select an option.

4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)

Please select an option.

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?)

Please select an option.

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)

Please select an option.

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)

Please select an option.

8. Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)

Please select an option.

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)

Please select an option.

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?)

Please select an option.

11. When you smile at your child, does he or she smile back at you?

Please select an option.

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?)

Please select an option.

13. Does your child walk?

Please select an option.

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?

Please select an option.

15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)

Please select an option.

16. If you turn your head to look at something, does your child look around to see what you are looking at?

Please select an option.

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”?)

Please select an option.

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”?)

Please select an option.

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?)

Please select an option.

20. Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)

Please select an option.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Subscribe to updates from New Beginnings Pediatrics