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Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g., you've seen it once or twice), please answer as if the child does not do it.

M-Chat Form
Last Name *
First Name *
Date of Birth  /  / 
Health provider who asked you to do this questionnaire *
Does your child enjoy being swung, bounced on your knee, etc.? * YesNo
Does your child take an interest in other children? * YesNo
Does your child like climbing on things, such as up stairs? * YesNo
Does your child enjoy playing peek-a-boo/hide-and-seek? * YesNo
Does your child ever pretend, for example, to talk on the phone or take care of dolls, or pretend other things? * YesNo
Does your child ever use his/her index finger to point, to ask for something? * YesNo
Does your child ever use his/her index finger to point, to indicate interest in something? * YesNo
Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them? * YesNo
Does your child ever bring objects over to you (parent) to show you something? * YesNo
Does your child look you in the eye for more than a second or two? * YesNo
Does your child ever seem oversensitive to noise? (e.g., plugging ears) * YesNo
Does your child smile in response to your face or your smile? * YesNo
Does your child imitate you? (e.g., you make a face-will your child imitate it?) * YesNo
Does your child respond to his/her name when you call? * YesNo
If you point at a toy across the room, does your child look at it? * YesNo
Does your child walk? * YesNo
Does your child look at things you are looking at? * YesNo
Does your child make unusual finger movements near his/her face? * YesNo
Does your child try to attract your attention to his/her own activity? * YesNo
Have you ever wondered if your child is deaf? * YesNo
Does your child understand what people say? * YesNo
Does your child sometimes stare at nothing or wander with no purpose? * YesNo
Does your child look at your face to check your reaction when faced with something unfamiliar? * YesNo
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