Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g., you’ve seen it once or twice) please answer as if the child did not do it.

1. Does your child enjoy being swung, bounced on your knee, etc? YesNo

2. Does your child take an interest in other children? YesNo

3. Does your child like climbing on things, such as up stairs? YesNo

4. Does your child enjoy playing peek- boo/hide and seek? YesNo

5. Does your child ever pretend, for example, to talk on the phone or take care of Dolls, or pretend other things? YesNo

6. Does your child ever use his/her index finger to point, to ask for something? YesNo

7. Does your child ever use his/her index finger to point, to indicate interest in something? YesNo

8. Can your child play properly with small toys(e.g. cars or bricks without just Mouthing, fiddling, or dropping them? YesNo

9. Does your child ever bring objects over to you (parent) to show you something? YesNo

10. Does your child look you in the eye for more than a second or two? YesNo

11. Does your child ever seem oversensitive to noise? (e.g., plugging ears) YesNo

12. Does your child smile in response to your face or smile? YesNo

13. Does your child imitate you? (e.g., you make a face-will your child imitate it) YesNo

14. Does your child respond to his/her name when you call? YesNo

15. If you point at a toy across the room, does your child look at it? YesNo

16. Does your child walk? YesNo

17. Does your child look at things you are looking at? YesNo

18. Does your child make unusual finger movements near his/her face? YesNo

19. Does your child try to attract your attention to his/her own activity? YesNo

20. Have you ever wondered if your child is deaf? YesNo

21. Does your child understand what people say? YesNo

22. Does your child sometimes stare at nothing or wander with no purpose? YesNo

23. Does your child look at your face to check your reaction when faced with something unfamiliar? YesNo