Pediatric Behavior Checklist
Patients Name:
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First Name
Last Name
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Does your child take an interest in other children?
Does your child enjoy playing peek-a-book or hiding games?
Does your child ever pretend (talking on the phone, feeding dolls, etc?)
Does your child recognize him/herself in a photo?
Does your child use his/her finger to point?
Can your child play properly with toys (blocks, puzzles, etc) without just dropping or mouthing or throwing them?
Does your child ever bring something to show you?
Does your child ever look you in the eye for more than a second or two?
Does your child smile in response to your smile?
Does your child imitate faces you make or noises that you make?
Does your child respond when you call his/her name?
If you point to something, does your child look to where you are pointing?
Does your child understand what people say?
Does your child sometimes stare into thin air?
Was there ever a time your child seemed to developing speech and then stopped?
Does your child "echo" everything he/she hears?
Is your child too friendly with strangers?
Does your child constantly line up objects or toys?
Does your child inflict self-injury?
Does your child resist being "friendly" with friends?
Does your child spin objects or themselves a lot?
Does your child laugh or giggle or cry for no apparent reason?
Does your child have temper tantrums for reasons that are not clear to you?
Does your child want to stick to a routine and do things in the same order or in the same way every day?
Do changes in routines result in tantrums?
Is your child bothered by clothing and end up taking it off all the time?
Is your child a picky eater?
Does he/she only like to eat certain textures?
Does your child hate to get his/her haircut?
Does your child hate to have fingernails trimmed?
Does your child enjoy constant swinging, bouncing, or other active repetitive movement?
Does your child ever seem oversensitive to noise?
Does your child make unusual finger movements near his/her face?
Have you ever wondered if your child might have a hearing loss?
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