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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..
Hold their head up
Push up with their arms when on their belly
Put weight through both feet
Bring their hands to their mouth
Roll from their belly to their back
Roll from their back to their belly
Sits briefly without help
Bring hands to their knees or plays with with toes
Sit without help with good posture
Stand with help
Reach for toys outside of reach while in sitting
Army crawl in a circle (pivot) to reach toys while on belly
Get into a hands and knees crawling position
Crawl on hands and knees
Pull themselves up into a standing position
While holding on, side step to the left and right
Sit back down after pulling themself up
Stand briefly without holding on
Take a few steps on their own
Stand up from the middle of the floor
Crawl up or down stairs
Grab and shake a toy
Eat with a spoon
Drink from open cup or straw cup
Pick up small pieces of food with their finger and thumb?
Clap their hands?
Question 6 of 6
Does your child..
Prefer to look to one direction?
Feel floppy?
Feel stiff?
Have a flat spot on their head?
Only want to stand?
Only want to sit?
Arch their back frequently?
Move one arm more than the other?
Unable to keep their head in the middle?
Not able to put weight through their feet?
Want to be up on their tip toes when in standing?
Not tolerate tummy time?
Dislike changing clothes?
Not sleep well?
Struggle with bath time?
Hate the car or car seat?
Struggle with loud or sudden noises?
Not like certain textures?
Refuse certain foods/food textures?
Avoid getting dirty?
Look anxious while playing in certain positions or in certain environments?
Have a hard time calming when upsite?
Constantly on the move?
Struggle with drinking from specifics bottles or cups?
Spill milk/food/water from their mouth while eating from breast/bottle/cup?
Make a lot of noises while eating? Like clicking, smacking lips, etc.