12-Month Milestones Checklist
Track and assess your child's developmental milestones at 12 months. Please complete the checklist accurately to help monitor progress.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Male
Female
Other / Prefer not to say
Your Full Name
*
First Name
Last Name
Your Relationship to the Child
*
Please Select
Parent/Guardian
Grandparent
Caregiver
Other
Milestone Checklist: Please indicate if your child regularly demonstrates the following skills.
*
Rows
Yes
Sometimes
Not Yet
Pulls up to stand
1
2
3
Walks holding on to furniture (cruising)
4
5
6
Picks up small objects with thumb and finger
7
8
9
Says simple words like “mama” or “dada”
10
11
12
Responds to own name
13
14
15
Waves bye-bye
16
17
18
Plays simple games like peek-a-boo
19
20
21
Understands simple instructions (e.g., “no”)
22
23
24
Shows affection to familiar people
25
26
27
Looks at objects when named
28
29
30
How concerned are you about your child's development?
*
Not at all concerned
1
2
3
4
Very concerned
5
1 is Not at all concerned, 5 is Very concerned
Please rate your child's overall progress in the past 3 months.
*
1
2
3
4
5
Does your child have any medical conditions or special needs?
*
No
Yes (please specify below)
If yes, please specify any medical conditions or special needs.
Additional comments or concerns
Submit Checklist
Should be Empty: