M-CHAT (Modified Checklist for Autism in Toddlers)

Child's Name

Today's Date

Date of Birth

Filled Out By

Relationship to Child

Please fill out the following about how your child usually is. Please try to answer every question. If behavior is rare (e.g., you've seen it once or twice, please answer as if your child does not do it.)

1. Does your child enjoy being swung, bounced on your knee, etc.?

Yes No

2. Does your child take an interest in other children?

Yes No

3. Does your child like climbing on things, such as up stairs?-

Yes No

4. Does your child enjoy playing peek-a-boo/hide-and-seek?

Yes No

5. Does your child ever pretend, for example, to talk on the phone or take care of dolls, or pretend other things?

Yes No

6. Does your child ever use his/her index finger to point, to ask for something?

Yes No

7. Does your child ever use his/her index finger to point, to indicate interest in something?

Yes No

8. Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them?

Yes No

9. Does your child ever bring objects over to you (parent) to show you something?

Yes No

10. Does your child look you in the eye for more than a second or two?

Yes No

11. Does you child ever seem oversensitive to noise? (e.g. plugging ears)

Yes No

12. Does your child smile in response to your face or your smile?

Yes No

13. Does your child imitate you? (e.g. You make a face-Will your child imitate it?)

Yes No

14. Does your child respond to his/her name when you call?

Yes No

15. If you point at a toy across the room, does your child look at it?

Yes No

16. Does your child walk?

Yes No

17. Does your child look at things you are looking at?

Yes No

18. Does your child make unusual finger movements near his/her face?

Yes No

19. Does your child try to attract your attention to his/her own activity?

Yes No

20. Have you ever wondered if your child is deaf?

Yes No

21. Does your child understand what people say?

Yes No

22. Does your child sometimes stare at nothing or wander with no purpose?

Yes No

23. Does your child look at your face to check your reaction when faced with something unfamiliar?

Yes No

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