11 months 0 days through 12 months 30 days
GROSS MOTOR TOTAL (sum of all points according to answers chosen; see numbers below options) Delayed = below 20. Borderline 20 - 35. Normal 40 - 60.
FINE MOTOR TOTAL (sum of all points according to answers chosen; see numbers below options) Delayed = below 35. Borderline 35 - 40. Normal 45 - 60. *If Fine Motor Item 4 is marked “yes” or “sometimes,” mark Fine Motor Item 2 “yes.”
PROBLEM SOLVING TOTAL (sum of all points according to answers chosen; see numbers below options) Delayed = below 25. Borderline 25 - 35. Normal 40 - 60. *If Problem Solving Item 5 is marked “yes” or “sometimes,” mark Problem Solving Item 4 “yes.”
PERSONAL-SOCIAL TOTAL (sum of all points according to answers chosen; see numbers below options) Delayed = below 20. Borderline 20 - 30. Normal 35 - 60.
Parents and providers may use the space below for additional comments.
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