We Nurture Foundation

Please answer these questions about your child keeping in mind behavior/approach in natural environment. If the occurrence is observed most of the time, please mark ‘Yes’.

Parent Name

Child Date Of Birth

Mobile Number

Email Address

Age

Relationship with child

Is the child exhibiting meaningful pretend play/make-believe play with toys?

Yes

Is the child having a scattered attention, less eye contact and no eye gaze shifts?

Yes

Is the child having discomfort eating mixed texture?

Yes

Does your child respond to name call?

Yes

Is the child having repetitive hand movements or unusual hand movements? Example: wiggle, hand flapping or jerk movements or bring fingers near eyes.

Yes

Is the child always on the move?

Yes

Does the child show interest in manipulating or exploring objects?

Yes

Does the child exhibit patterns while playing?

Yes

Does your child imitate simple actions? Example: Wave bye-bye, clap hands, hi-fi

Yes

Does the child like movement activities? Example: rocking or bouncing on knee or play in the swing for longer time

Yes

Does your child have meaningful pointing of objects?

Yes

Does your child protest/exhibit tantrum when any change in routine is made?

Yes

Does the child show behavior while eating food?

Yes

Is the child attending to a particular activity for less than 5 minutes?

Yes

Does your child have regular constipation issues?

Yes

Does the child have a social smile or reciprocating smile?

Yes

Does your child co-operate when an activity is changed?

Yes

Does your child show interest when ‘how’ or ‘why’ about objects are explained? Example: a new activity or simple coloring or drawing when explained

Yes

Is the child interested in playing with other children of same age?

Yes

Does your child insist in playing as per his/her wish most of the times?

Yes

Does your child have regular sleep disturbance? Example: Sleep very late or wake up very early or at mid night?

Yes

Quick Assessment Caregiver Questionnaire