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Questionnaire
24
Questions
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1
Child's Name
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First Name
Last Name
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2
Today's Date
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Date
Day
Month
Year
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3
Date of Birth
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Date
Year
Month
Day
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4
If baby was born 3 or more weeks prematurely
Number of weeks premature
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5
Months premature
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6
Age days
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7
Age months
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8
Person filling out questionnaire
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First Name
Last Name
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9
Parent's Email
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example@example.com
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10
Important Points to Remember:
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11
COMMUNICATION
Yes
Sometimes
Not yet
1. Does your baby sometimes make throaty or gurgling sounds?
2. Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?
3. When you speak to your baby, does she make sounds back to you?
4. Does your baby smile when you talk to him?
5. Does your baby chuckle softly?
6. After you have been out of sight, does your baby smile or get excited when she sees you?
1. Does your baby sometimes make throaty or gurgling sounds?
2. Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?
3. When you speak to your baby, does she make sounds back to you?
4. Does your baby smile when you talk to him?
5. Does your baby chuckle softly?
6. After you have been out of sight, does your baby smile or get excited when she sees you?
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
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12
GROSS MOTOR
Yes
Sometimes
Not yet
1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?
2. When your baby is on her tummy, does she turn her head to the side?
3. When your baby is on his tummy, does he hold his head up longer than a few seconds?
4. When your baby is on her back, does she kick her legs?
5. While your baby is on his back, does he move his head from side to side?
6. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?
1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?
2. When your baby is on her tummy, does she turn her head to the side?
3. When your baby is on his tummy, does he hold his head up longer than a few seconds?
4. When your baby is on her back, does she kick her legs?
5. While your baby is on his back, does he move his head from side to side?
6. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
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Yes
Sometimes
Not yet
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13
FINE MOTOR
Yes
Sometimes
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1. Is your baby’s hand usually tightly closed when he is awake? (If your baby used to do this but no longer does, mark “yes.”)
2. Does your baby grasp your finger if you touch the palm of her hand?
3. When you put a toy in his hand, does your baby hold it in his hand briefly?
4. Does your baby touch her face with her hands?
5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?
6. Does your baby grab or scratch at her clothes?
1. Is your baby’s hand usually tightly closed when he is awake? (If your baby used to do this but no longer does, mark “yes.”)
2. Does your baby grasp your finger if you touch the palm of her hand?
3. When you put a toy in his hand, does your baby hold it in his hand briefly?
4. Does your baby touch her face with her hands?
5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?
6. Does your baby grab or scratch at her clothes?
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
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Yes
Sometimes
Not yet
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14
PROBLEM SOLVING
Yes
Sometimes
Not yet
1. Does your baby look at objects that are 8–10 inches away?
2. When you move around, does your baby follow you with his eyes?
3. When you move a toy slowly from side to side in front of your baby’s face (about 10 inches away), does your baby follow the toy with her eyes, sometimes turning her head?
4. When you move a small toy up and down slowly in front of your baby’s face (about 10 inches away), does your baby follow the toy with his eyes?
5. When you hold your baby in a sitting position, does she look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?
6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?
1. Does your baby look at objects that are 8–10 inches away?
2. When you move around, does your baby follow you with his eyes?
3. When you move a toy slowly from side to side in front of your baby’s face (about 10 inches away), does your baby follow the toy with her eyes, sometimes turning her head?
4. When you move a small toy up and down slowly in front of your baby’s face (about 10 inches away), does your baby follow the toy with his eyes?
5. When you hold your baby in a sitting position, does she look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?
6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
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15
PERSONAL-SOCIAL
Yes
Sometimes
Not yet
1. Does your baby sometimes try to suck, even when she’s not feeding?
2. Does your baby cry when he is hungry, wet, tired, or wants to be held?
3. Does your baby smile at you?
4. When you smile at your baby, does she smile back?
5. Does your baby watch his hands?
6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?
1. Does your baby sometimes try to suck, even when she’s not feeding?
2. Does your baby cry when he is hungry, wet, tired, or wants to be held?
3. Does your baby smile at you?
4. When you smile at your baby, does she smile back?
5. Does your baby watch his hands?
6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
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Yes
Sometimes
Not yet
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16
1. Did your baby pass the newborn hearing screening test? If no, explain:
Yes
No
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17
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18
2. Does your baby move both hands and both legs equally well? If no, explain:
Yes
No
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19
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20
3. Does either parent have a family history of childhood deafness, hearing impairment, or vision problems? If yes, explain:
Yes
No
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21
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22
4. Has your baby had any medical problems? If yes, explain:
Yes
No
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23
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24
5. Do you have concerns about your baby’s behavior (for example, eating, sleeping)? If yes, explain:
Yes
No
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25
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26
6. Does anything about your baby worry you? If yes, explain:
Yes
No
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27
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28
COMMUNICATION SCORE
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29
COMMUNICATION SCORE
< 20 below expected and needs assessment and follow-up 21-35 close to expected and needs additional learning activities and follow-up >35 Above expected and development appears to be on schedule
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30
GROSS MOTOR SCORE
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31
GROSS MOTOR SCORE
< 40 below expected and needs assessment and follow-up 40-45 close to expected and needs additional learning activities and follow-up >45 Above expected and development appears to be on schedule
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32
FINE MOTOR SCORE
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33
FINE MOTOR SCORE
< 30 below expected and needs assessment and follow-up 30-40 close to expected and needs additional learning activities and follow-up >40 Above expected and development appears to be on schedule
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34
PROBLEM SOLVING SCORE
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35
PROBLEM SOLVING SCORE
< 25 below expected and needs assessment and follow-up 25-35 close to expected and needs additional learning activities and follow-up >35 Above expected and development appears to be on schedule
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36
PERSONAL-SOCIAL SCORE
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37
PERSONAL-SOCIAL SCORE
< 30 below expected and needs assessment and follow-up 30-40 close to expected and needs additional learning activities and follow-up >40 Above expected and development appears to be on schedule
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