Developmental Summary Form

Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Name of Person Completing this Form *
Name of Person Completing this Form
Medical and Developmental History
Please indicate what age your child achieved the following milestones:
Please check any of the following that apply to your child:
Please fill out any questions below that would be helpful in assessing your child’s needs. Some questions may not apply to your child.
Does your child combine words (i.e.,“more cookie”)?
Does your child follow directions?
Does your child appropriately communicate wants and needs?
Does your child spontaneously communicate thoughts and ideas?
Does your child display appropriate eye contact when communicating with others?
Is your child able to attend to and complete age appropriate tasks?
Does your child tolerate different textures, noisy environments, and all kinds movement?
Does your child have difficulties with transitions?
Is your child able to self-regulate to meet the demands of his or her environment?
Does your child use utensils (spoon, fork)?
Does your child self-feed finger foods?
Does your child take shoes/socks off?
Does your child take clothes off and put clothes on?
Does your child tolerate bath time?
Is your child potty trained?
Does your child demonstrate adequate strength/endurance?
Does your child have any difficulty climbing stairs?
Is your child able to scribble, stack blocks, and/or string beads?