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Free Screening Form

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Question 1 of 6

By typing your name and phone number below, you agree and consent for milestones therapy + wellness to complete a complimentary screen for your child.

Question 2 of 6

What is your child's name and age?

Question 3 of 6

Does your child have a medical diagnosis? If yes, elaborate

Question 4 of 6

Do you have any concerns about your child's development?

Question 5 of 6

Is your child able to.. 

(Select all that apply)
A

Hold their head up

B

Push up with their arms when on their belly

C

Put weight through both feet

D

Bring their hands to their mouth

E

Roll from their belly to their back

F

Roll from their back to their belly

G

Sits briefly without help

H

Bring hands to their knees or plays with with toes

I

Sit without help with good posture

J

Stand with help

K

Reach for toys outside of reach while in sitting

L

Army crawl in a circle (pivot) to reach toys while on belly

M

Get into a hands and knees crawling position

N

Crawl on hands and knees

O

Pull themselves up into a standing position

P

While holding on, side step to the left and right

Q

Sit back down after pulling themself up

R

Stand briefly without holding on

S

Take a few steps on their own

T

Stand up from the middle of the floor

U

Crawl up or down stairs

V

Grab and shake a toy

W

Eat with a spoon

X

Drink from open cup or straw cup

Y

Pick up small pieces of food with their finger and thumb?

Z

Clap their hands?

Question 6 of 6

Does your child..

(Select all that apply)
A

Prefer to look to one direction?

B

Feel floppy?

C

Feel stiff?

D

Have a flat spot on their head?

E

Only want to stand?

F

Only want to sit?

G

Arch their back frequently?

H

Move one arm more than the other?

I

Unable to keep their head in the middle?

J

Not able to put weight through their feet?

K

Want to be up on their tip toes when in standing?

L

Not tolerate tummy time?

M

Dislike changing clothes?

N

Not sleep well?

O

Struggle with bath time?

P

Hate the car or car seat?

Q

Struggle with loud or sudden noises?

R

Not like certain textures?

S

Refuse certain foods/food textures?

T

Avoid getting dirty?

U

Look anxious while playing in certain positions or in certain environments?

V

Have a hard time calming when upsite?

W

Constantly on the move?

X

Struggle with drinking from specifics bottles or cups?

Y

Spill milk/food/water from their mouth while eating from breast/bottle/cup?

Z

Make a lot of noises while eating? Like clicking, smacking lips, etc.

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