This information is optional. It is not stored and used only for inclusion on the assessment result printout.
Child's First Name:
Child's Surname:
Age:
Does your child:
Have difficulty rolling over freely in all directions?
Have difficulty taking steps sideways whilst holding onto furniture (cruising)?
Have difficulty taking a few steps forward with hands held?
Have difficulty taking weight through their feet in standing with support from you?
Have difficulty rolling onto their side if encouraged with a toy?
Have difficulty pulling themselves forwards towards a toy with their arms whilst on their tummy (commando crawling)?
Have difficulty rolling over from their tummy to their back?
Have difficulty crawling forwards on their hands and knees compared to same aged peers?
Scoot along on their bottom (bottom shuffling) in preference to crawling?
Does your child have difficulty:
Have difficulty sitting alone for 60 seconds or more?
Have difficulty sitting with their hands free for play for 30 seconds or more?
Appear to wobble a lot when placed in sitting?
Have difficulty keeping their chin against their chest when pulled from lying to sitting?
Appear slumped forwards when sitting (not able to sit upright with a straight back)?
Successfully reaching for a toy when lying on their tummy without falling to the side?
Sitting independently for more than 30 seconds whilst playing with a toy in their hands?
Leaning forward when sitting to get a toy without losing balance?
Standing independently while playing with a toy?
Lowering toward a squatting position with hand support to pick up a toy?
Lie still when placed on their back (no attempt to actively kick their legs etc)?
Have difficulty bringing their hands together in the middle of their body to attempt to play with a toy?
Have difficulty bringing their hands and feet together in the middle of their body?
Have difficulty keeping their head in line with their body (doesn’t lag behind) when they are pulled to sit up?
Have difficulty keeping their head still while following a toy with their eyes?
Have difficulty standing with hands free (less than 5 seconds)?
Have difficulty lowering themselves with control from standing to sitting on the floor?
Have difficulty standing with their feet a similar width apart to other children of a similar age?
Look unsteady when standing such that you would not feel safe to move out of reach?
Have difficulty using one hand to play with a toy whilst standing?
Become upset or dislike being placed on their tummy for an extended period?
Have difficulty lifting their head from the floor and turning it to the other side?
Have difficulty propping themselves up on both arms?
Have difficulty propping themselves on one arm to reach for a toy in front of them?
Have difficulty propping themselves on one arm and reach for a toy behind them without rolling over?
Remain still when placed on their back?
Have difficulty attempting to roll away during play?
Have difficulty helping themselves into sitting from lying while holding your hands?
Lose interest in play quickly compared to those of a similar age?
Become frustrated easily?
Have difficulty staying upright when supported around the hips in standing?
Appear floppy in nature compared to other children of a similar age?
Have splayed legs (like a frog) when lying on their back?
Appear to get tired quicker than those of a similar age during play?
Have difficulty pulling themselves up into kneeling or standing at low furniture to play?
Have difficulty engaging in play (e.g. taking turns)?
Show limited interest in putting toys in their mouth?
Have limited interest in banging toys together in amusement?
Have difficulty swapping a toy from hand to hand?
Have difficulty copying/mimicking your gestures such as waving?
Show little interest in looking at you or joining in during play (i.e. not smiling/laughing/babbling)?
Have difficulty following a toy of interest?
Show limited desire in reaching for a toy of interest when sitting, or lying down?
Appear disinterested in activities despite encouragement?
Become distracted easily?
Scoot along on their bottom (bottom shuffle) to get around despite children of a similar age not doing this?
Choose the easier option during activities (e.g. goes around the obstacle instead of over it)?
Have limited curiosity when presented with new/more challenging toys?
Have difficulty copying children of similar ages during play?
Moving about in a similar way to children of a similar age?