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Mile Stone Checklist Model
File No
Date Of Reg.
Patient Name
Therapist Name
Motor
while lying on tummy, pushes up on arms
While lying on tummy, lifts and holds head up
Able to move fists from closed to open
Able to bring hands to mouth
Moves legs and arms off of surface when excited
Sensory
While lying on back, visually tracks an moving toy from side to side
While lying on back, attempts to reach for a toy held above their chest
While lying on back, keeps head centered to watch faces or toys
Able to calm with rocking, touching, and gentle sounds
Communication
Makes eye contact
Cries differently for different needs
Coos and smiles
Turns head towards sound or voice
Quiets or smiles in response to sound or voice
Shows interest in faces
Feeding
Latches onto nipple or bottle
Tongue moves forward and back to such
Drinks 2oz. t0 6oz. of liquid per feeding, 6 times per day
Sucks and swallows well during feeding
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