Child's Name
*
First Name
Last Name
Today's Date
-
Day
-
Month
Year
Date
Date of Birth
-
Year
-
Month
Day
Date
If baby was born 3 or more weeks prematurely
Months premature
Age days
Age months
Person filling out questionnaire
*
First Name
Last Name
Parent's Email
*
example@example.com
On the following pages are questions about activities babies may do. Your baby may have already done some of the activitiesdescribed here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicateswhether your baby is doing the activity regularly, sometimes, or not yet.
COMMUNICATION
*
Yes
Sometimes
Not yet
1. If you call to your baby when you are out of sight, does she look in the direction of your voice?
2. When a loud noise occurs, does your baby turn to see where the sound came from?
3. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?
4. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?
5. Does your baby respond to the tone of your voice and stop his activity at least briefly when you say “no-no” to him?
6. Does your baby make two similar sounds like “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)
GROSS MOTOR
*
Yes
Sometimes
Not yet
1. When you put your baby on the floor, does she lean on her hands while sitting? (If she already sits up straight without
leaning on her hands, mark “yes” for this item.)
2. Does your baby roll from his back to his tummy, getting both arms out from under him?
3. Does your baby get into a crawling position by getting up on her hands and knees?
4. If you hold both hands just to balance your baby, does he support his own weight while standing?
5. When sitting on the floor, does your baby sit up straight for several minutes without using her hands for support?
6. When you stand your baby next to furniture or the crib rail, does he hold on without leaning his chest against the furniture for support?
FINE MOTOR
*
Yes
Sometimes
Not yet
1. Does your baby reach for a crumb or Cheerio and touch it with her finger or hand? (If she already picks up a small object, mark “yes” for this item.)
2. Does your baby pick up a small toy, holding it in the center of his hand with his fingers around it?
3. Does your baby try to pick up a crumb or Cheerio by using her thumb and all of her fingers in a raking motion, even if she isn’t able to pick it up? (If she already picks up a crumb or Cheerio, mark “yes” for this item.)
4. Does your baby pick up a small toy with only one hand?
5. Does your baby successfully pick up a crumb or Cheerio by using his thumb and all of his fingers in a raking motion? (If he already picks up a crumb or Cheerio, mark “yes” for this item.)
6. Does your baby pick up a small toy with the tips of her thumb and fingers? (You should see a space between the toy and her palm.)
PROBLEM SOLVING
*
Yes
Sometimes
Not yet
1. Does your baby pick up a toy and put it in his mouth?
2. When your baby is on her back, does she try to get a toy she has dropped if she can see it?
3. Does your baby play by banging a toy up and down on the floor or table?
4. Does your baby pass a toy back and forth from one hand to the other?
5. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?
6. When holding a toy in his hand, does your baby bang it against another toy on the table?
PERSONAL-SOCIAL
*
Yes
Sometimes
Not yet
When lying on her back, does your baby play by grabbing her foot?
2. When in front of a large mirror, does your baby reach out to pat the mirror?
3. Does your baby try to get a toy that is out of reach? (He may roll, pivot on his tummy, or crawl to get it.)
4. While your baby is on her back, does she put her foot in her mouth?
5. Does your baby drink water, juice, or formula from a cup while you hold it?
6. Does your baby feed himself a cracker or a cookie?
OVERALL
Parents and providers may use the space below for additional comments.
1. Does your baby use both hands and both legs equally well? If no, explain:
*
Yes
No
2. When you help your baby stand, are his feet flat on the surface most of the time? If no, explain:
*
Yes
No
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:
*
Yes
No
4. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:
*
Yes
No
5. Do you have concerns about your baby’s vision? If yes, explain:
*
Yes
No
6. Has your baby had any medical problems in the last several months? If yes, explain:
*
Yes
No
7. Do you have any concerns about your baby’s behavior? If yes, explain:
*
Yes
No
8. Does anything about your baby worry you? If yes, explain:
*
Yes
No
COMMUNICATION SCORE
COMMUNICATION SCORE
< 30 below expected and needs assessment and follow-up 30-35 close to expected and needs additional learning activities and follow-up >40 Above expected and development appears to be on schedule
GROSS MOTOR SCORE
GROSS 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
FINE MOTOR SCORE
FINE 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
PROBLEM SOLVING SCORE
PROBLEM SOLVING SCORE
< 35 below expected and needs assessment and follow-up 35-45 close to expected and needs additional learning activities and follow-up >45 Above expected and development appears to be on schedule
PERSONAL-SOCIAL SCORE
PERSONAL-SOCIAL SCORE
< 35 below expected and needs assessment and follow-up 35-45 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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