M-CHAT Form

Patient Name:

D.O.B.:

Completed By:

Provider Reviewed:

Modified Checklist of Autism in Toddlers (M-CHAT)

* Attention: Perform at 18month & 2yr exams

Please fill out the following about how your child USUALLY is. If the behavior is rare (you’ve only seen it once or twice), please answer no. Please answer all questions.

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 upstairs?

YES NO

4. Does your child enjoy playing peek-a-boo, hide & seek?

YES NO

5. Does your child ever pretend (ex: talk on the phone, take care of dolls or pretend other things)?

YES NO

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

YES NO

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

YES NO

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

YES NO

9. Does your child ever bring objects to you 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 your child ever seem oversensitive to noise (plugs his/her ears)?

YES NO

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

YES NO

13. Does your child imitate you (if you make a face for example)?

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

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

Your information will be encrypted.