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Eye Contact & Command Following Screening Form
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Name
*
Email
*
contact: Gender Email
Moblie Number
*
Age
*
Gender
---Select---
Male
Female
Other
Any Prior Diagnosis (if any):
Rate your child’s command-following ability:
---Select---
1
2
3
4
5
(1 = Rarely follows commands, 5 = Follows easily)
Rate your child’s eye contact:
---Select---
1
2
3
4
5
(1 = Very limited, 5 = Good eye contact)
Submit
