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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, they don’t automatically move them back into a bent position.

Yes

No

2. My baby is more dominant on their left or right side (they are not symmetrical in use of both sides).

True

False

3. I would describe my baby as extremely floppy/ loosey goosey.

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 has excessive head lagging behind their body when pulled up to sit from 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. My baby accepts weight in their legs when placed in “standing” position.

True

False

10. My baby attempts to “walk” (note parentheses because this is a reflex, not voluntary) when placed in a standing position.

True

False

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