Email *

Child Date of Birth *

If they were premature, please identify their adjusted age. This assessment goes off of adjusted ages.

1. How would you describe your baby’s muscle tone when you hold or touch them?

Floppy or soft

Tight or stiff

in between

2. I feel comfortable leaving my baby in a sitting position when I leave the room.

True

False

3. When you think about your baby, or look at pictures of them, is their head usually tilted or turned to one side? Do they have a flat spot on their head?

Yes

It's hard to tell

No

4. How does your baby move around on the floor?

Rolling

Army Crawling

Butt Scooting

A Funky Thing I can't Even Name

Hands and Knees

5. My baby can move between the floor and sitting on their own.

True

False

6. My baby is starting to get onto their knees to see things on tables or couches.

True

False

7. My baby is starting to pull themselves up from the floor to a standing position.

True

False

8. Does your baby spend a lot of time in a bouncer, jumper, walker, car seat, or in your arms?

Yes; I need to keep them contained or held because otherwise they will cry

Yes; I have a lot to get done and this is how I manage my tasks

No; they are able to explore their environment without restraint

9. When you hold your baby in a standing position, how do they stand?

Lock out their knees and push their booty back

Stand on tiptoes

Jump nonstop

Stand upright on flat feet and sometimes even bounce

10Does your baby show a clear preference for one side (looking, reaching, pulling up to stand).

Yes; I think they may already be showing they’re a “lefty” or a “righty”

No

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