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Child Date of Birth

If your baby was born premature, what is their adjusted age?

1. When you straighten your baby's arms/ legs, do they return to a bent position on their own?

Yes

No

2. My baby tends to use one side of their body more than the other (for example, the left or right side).

True

False

3. My baby feels very floppy or unusually loose when I hold them.

True

False

4. When on their back, my baby is moving their eyes to follow targets (several inches away).

True

False

5. My baby is kicking their legs.

True

False

6. My baby mostly keeps their arms and legs straight.

True

False

7. My baby's head falls back excessively when pulled to a sitting position from lying on their back.

True

False

8. My baby's legs have difficulty bending (ex. diaper changes and putting pants on/off is a struggle).

True

False

9. When I hold my baby in a standing position, they can support some of their weight on their legs.

True

False

10. When held in a standing position, my baby makes stepping movements with their legs (this is a reflex, not intentional walking). 

True

False

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