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Infant Development Screening Form - Free Healthcare Template | ZenBuild | ZenBuild

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Infant Development Screening Form

Developmental screening questionnaire for infants and toddlers to identify potential delays in motor, language, and social skills. Designed for pediatricians and early intervention programs.

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Infant Development Screening

Please answer the following questions about your child's development. This helps us identify any areas where early support might be helpful.

Child's Name*

Child's Date of Birth*

Child's Age in Months*

Parent / Guardian Name*

Does your child respond to their name when called?*

Yes, consistentlySometimesRarely or never

Does your child make eye contact and smile at people?*

YesSometimesRarely or never

Motor Skills Observed (select all that apply)

Holds head upRolls overSits without supportCrawlsPulls to standWalks independentlyGrasps small objects

Does your child babble, say words, or try to communicate?*

Uses words or word-like soundsBabbles and gesturesVery little vocalization

Any Concerns About Your Child's Development?

Template Details

CategoryHealthcare

IndustryHealthcare

Fields9

Uses0

Views1

healthcarepediatricsdevelopmental-screeninginfant