Infant Development Screening Form

Infant Development Screening Form — Form Fields

This healthcare template includes 9 fields. Developmental screening questionnaire for infants and toddlers to identify potential delays in motor, language, and social skills. Designed for pediatricians and early intervention programs. Free to customize and use on ZenBuild.

• Child's Name (text, required)
• Child's Date of Birth (text, required)
• Child's Age in Months (number, required)
• Parent / Guardian Name (text, required)
• Does your child respond to their name when called? (multiple choice, required) — options: Yes, consistently, Sometimes, Rarely or never
• Does your child make eye contact and smile at people? (multiple choice, required) — options: Yes, Sometimes, Rarely or never
• Motor Skills Observed (select all that apply) (checkboxes, optional) — options: Holds head up, Rolls over, Sits without support, Crawls, Pulls to stand, Walks independently, Grasps small objects
• Does your child babble, say words, or try to communicate? (multiple choice, required) — options: Uses words or word-like sounds, Babbles and gestures, Very little vocalization
• Any Concerns About Your Child's Development? (long text, optional)