M-CHAT

Today's Date:

Date

Patient's Name:

First NameLast Name

Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but they do not usually do it, then please answer no. Please mark yes or no for every question.

	Yes	No
1. If you point at something across the room, does your child look at it? (For example: if you point at a toy or an animal, does your child look at the toy or animal?)
2. Have you ever wondered if your child might be deaf?
3. Does your child play pretend or make-believe? (For example: pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)
4. Does your child like climbing on things? (For example: furniture, playground equipment, or stairs?)
5. Does your child make unusual finger movements near their eyes?
6. Does your child point with one finger to ask for something or to get help? (For example: pointing to a snack or toy that is out of reach?)
7. Does your child point with one finger to show you something interesting? (For example: pointing to an airplane in the sky or a big truck in the road?)
8. Is your child interested in other children? (For example: does your child watch other children, smile at them, or go to them?)
9. Does your child show you things by bringing them to your or holding them up for you to see - not to get help, but just to share? (For example: showing you a flower, a stuffed animal, or a toy?)
10. Does your child respond when you call their name? (For example: do they look up, talk or babble, or stop what they are doing when you call their name?)
11. When you smile at your child, do they smile back at you?
12. Does your child get upset by everyday noises? (For example: does your child scream or cry to noise such as a vacuum cleaner or loud music?)
13. Does your child walk?
14. Does your child look you in the eye when you are talking to them, playing with them, or dressing them?)
15. Does your child try to copy what you do? (For example: wave bye-bye, clap, or make a funny noise when you do?)
16. If you turn your head to look at something, does your child look around to see what you are looking at?
17. Does your child try to get you to watch them? (For example: does your child look at you for praise, or say, "Look!" or "Watch me!")
18. Does your child understand when you tell them to do something? (For example: if you don't point, can your child understand, "Put the book on the chair." or, "Bring me the blanket.")
19. If something new happens, does your child look at your face to see how you feel about it? (For example: if they hear a strange or funny noise, or sees a new toy, will they look at your face?)
20. Does your child like movement activities? (For example: being swung or bounced on your knee)

Number of Yes answers:

Number of No answers:

Is there anything you would like to bring to the attention of your provider?

M-CHAT-R