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(if applicable) EXAMINER Information provided by the client s parents/caregiver indicates that the client has a developmental age of: (alpha/numeric data) Outcome - Examination indicated client s developmental age is: (alpha/numeric data) Do you have any additional comments you wish to make Examiner s name Examiner s signature Date (YYYY-MM-DD) 1 - 2 MONTHS OF AGE ACTIVITIES TO BE OBSERVED ON EXAM ACTIVITIES RELATED BY PARENTS OR CAREGIVER Holds head erect and lifts head Recognizes parents Regards faces and follows objects through visual field Engages in vocalizations Becomes alert in response to voice Smiles spontaneously 3 - 5 MONTHS OF AGE ACTIVITIES TO BE OBSERVED ON EXAM ACTIVITIES RELATED BY PARENTS OR CAREGIVER Grasps cube - first ulnar then later thumb opposition Laughs Reaches for and brings objects to mouth Anticipates food on site Plays at making sounds Turns from back to side Sits with support 6 - 8 MONTHS OF AGE ACTIVITIES TO BE OBSERVED ON EXAM ACTIVITIES RELATED BY PARENTS OR CAREGIVER Sits alone for a short period Rolls from back to stomach Reaches with one hand Is inhibited by the word "NO" First scoops up a small object then grasps it using thumb opposition Imitates "bye-bye" and babbles Passes object from hand to hand in midline IMM 5738 (09-2012) E (AUSSI DISPONIBLE EN FRANÇAIS - IMM 5738 F) 3 Operations Directorate, Health Branch Immigration Medical Examination Instructions PAGE 2 OF 3 9 - 11 MONTHS OF AGE ACTIVITIES TO BE OBSERVED ON EXAM ACTIVITIES RELATED BY PARENTS OR CAREGIVER Stands holding on Walks by supporting self on furniture Imitates pat-a-cake and peek-a-boo Follows one-step commands e.g., "Come here" or "Give it to me" Uses thumb and index finger to pick up small object 1 YEAR OF AGE ACTIVITIES TO BE OBSERVED ON EXAM ACTIVITIES RELATED BY PARENTS OR CAREGIVER Walks independently Points to desired object Says "mama" and "dada" with meaning Says 1 or 2 words Can use a neat pincer grasp to pick up a small object Releases cube into c
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