Infant Developmental Milestone Screening

Infant Developmental Milestone Screening — Form Fields

This healthcare template includes 11 fields. Screening form for pediatricians assessing infant developmental milestone achievement. Free to customize and use on ZenBuild.

• Child's Name (text, required)
• Date of Birth (text, required)
• Parent/Guardian Name (text, required)
• Pediatrician Name (text, required)
• Age at Screening (dropdown selection, required) — options: 2 Months, 4 Months, 6 Months, 9 Months, 12 Months, 15 Months, 18 Months, 24 Months
• Gross Motor Skills (checkboxes, required) — options: Holds Head Up, Rolls Over, Sits Without Support, Crawls, Pulls to Stand, Walks Independently, Runs, Climbs Stairs
• Fine Motor Skills (checkboxes, optional) — options: Grasps Objects, Transfers Objects, Pincer Grasp, Stacks Blocks, Scribbles, Turns Pages
• Language/Communication (checkboxes, required) — options: Coos, Babbles, Says Mama/Dada, 2-3 Words, Points to Objects, Follows Simple Commands, 2-Word Phrases
• Social/Emotional (checkboxes, optional) — options: Social Smile, Stranger Anxiety, Waves Bye-Bye, Plays Peek-a-Boo, Parallel Play, Shows Affection
• Overall Assessment (dropdown selection, required) — options: On Track, Monitor - Mild Concern, Refer - Moderate Concern, Urgent Referral
• Clinical Notes and Recommendations (long text, optional)