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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 does not do it.
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1.
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Does
your child enjoy being swung, bounced on your knee, etc.?
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Yes
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No
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2.
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Does
your child take an interest in other children?
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Yes
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No
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3.
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Does
your child like climbing on things, such as up stairs?
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Yes
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No
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4.
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Does
your child enjoy playing peek-a-boo/hide-and-seek?
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Yes
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No
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5.
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Does
your child ever pretend, for example, to talk on the phone or take
care of dolls, or pretend other things?
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Yes
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No
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6.
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Does
your child ever use his/her index finger to point, to ask for
something?
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Yes
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No
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7.
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Does
your child ever use his/her index finger to point, to indicate
interest in something?
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Yes
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No
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8.
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Can
your child play properly with small toys (e.g. cars or bricks)
without just mouthing, fiddling, or dropping them?
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Yes
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No
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9.
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Does
your child ever bring objects over to you (parent) to show you
something?
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Yes
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No
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10.
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Does
your child look you in the eye for more than a second or two?
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Yes
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No
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11.
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Does
your child ever seem oversensitive to noise? (e.g., plugging ears)
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Yes
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No
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12.
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Does
your child smile in response to your face or your smile?
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Yes
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No
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13.
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Does
your child imitate you? (e.g., you make a face-will your child
imitate it?)
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Yes
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No
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14.
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Does
your child respond to his/her name when you call?
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Yes
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No
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15.
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If
you point at a toy across the room, does your child look at it?
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Yes
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No
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16.
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Does
your child walk?
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Yes
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No
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17.
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Does
your child look at things you are looking at?
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Yes
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No
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18.
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Does
your child make unusual finger movements near his/her face?
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Yes
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No
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19.
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Does
your child try to attract your attention to his/her own activity?
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Yes
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No
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20.
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Have
you ever wondered if your child is deaf?
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Yes
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No
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21.
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Does
your child understand what people say?
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Yes
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No
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21.
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Does
your child sometimes stare at nothing or wander with no purpose?
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Yes
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No
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23.
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Does
your child look at your face to check your reaction when faced
with something unfamiliar?
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Yes
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No
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