Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

BHARTI LALLA, MD

First Name * Last Name * Date of Birth: * Date of Completion: * Enjoy being swung, bounced on your knee, etc.? * Take an interest in other children? * Like climbing on things, such as up stairs? * Playing peek-a-boo/hide-and-seek? * Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things? Ever use his/her index finger to point, to ask for something? * Ever use his/her index finger to point, to indicate interest in something? * . Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them? * Ever bring objects over to you (parent) to show you something? * Look you in the eye for more than a second or two? * Seem oversensitive to noise? (e.g., plugging ears) * Ever bring objects over to you (parent) to show you something? * Look you in the eye for more than a second or two? Seem oversensitive to noise? (e.g., plugging ears) * Smile in response to your face or your smile? * Respond to his/her name when you call? * Imitate you? (e.g., you make a face-will your child imitate it?) * Point at a toy across the room, does your child look at it? * Does your child walk? * Does your child look at things you are looking at? * New Field53 * Make unusual finger movements near his/her face? * Try to attract your attention to his/her own activity? * Have you ever wondered if your child is deaf? * Understand what people say? Does your child look at your face to check your reaction when faced with something unfamiliar? Sometimes stare at nothing or wander with no purpose? Signature: *