M-Chat Child's Name(Required) First Last Age(Required)Parent/Caregiver's Name(Required) First Last 1. If you point at something across the room, does your child look at it?(Required)(For example: if you point at a toy or an animal, does your child look at it?) Yes No 2. Have you ever wondered if your child might be deaf?(Required) Yes No 3. Does your child play pretend or make-believe?(Required)(For example: pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?) Yes No Does your child like climbing on things?(Required)(For example: stairs, furniture, playground equipment.) Yes No 5. Does your child make unusual finger movements near his or her eyes?(Required)(For example: does your child wiggle his or her fingers close to his or her eyes?) Yes No 6. Does your child point with one finger to ask for something or to get help?(Required)(For example: pointing to a snack or toy out of reach.) Yes No 7. Does your child point with one finger to show you something interesting?(Required)(For example: pointing to an airplane in the sky or a big truck in the road.) Yes No 8. Is your child interested in other children?(Required)(For example: does your child watch other children, smile at them, or go to them?) Yes No 9. Does your child show you things by bringing them to you or holding them up for you to see — not to get help, but to share?(Required)(For example: showing you a flower, a stuffed animal, or a toy truck.) Yes No 10. Does your child respond when you call his or her name?(Required)(For example: does he/she look up, babble, or stop what he/she is doing?) Yes No 11. When you smile at your child, does he/she smile back?(Required) Yes No 12. Does your child get upset by everyday noises?(Required)(For example: a vacuum cleaner or loud music?) Yes No 13. Does your child walk?(Required) Yes No 14. Does your child look you in the eye when you talk to, play with, or dress him/her?(Required) Yes No 15. Does your child try to copy what you do?(Required)(For example: wave bye-bye, clap, make funny noises.) Yes No 16. If you turn your head to look at something, does your child look around to see what you’re looking at?(Required) Yes No 17. Does your child try to get you to watch him/her?(Required)(For example: look at you for praise, say “look” or “watch me”?) Yes No 18. Does your child understand when you tell him/her something?(Required)(For example: if you don’t point, can he/she understand “put the book on the chair” or “bring me the blanket”?) Yes No 19. If something new happens, does your child look at your face to see how you feel about it?(Required)(For example: if he/she hears a strange or funny noise or sees a new toy, will he/she look at you?) Yes No 20. Does your child like movement activities?(Required) Yes No CAPTCHA
