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4 Month Questionnaire 3 months 0 days through 4 months 30 days
28
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
-
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 chuckle softly?
2. After you have been out of sight, does your baby smile or get excited when he sees you?
3. Does your baby stop crying when she hears a voice other than yours?
4. Does your baby make high-pitched squeals?
5. Does your baby laugh?
6. Does your baby make sounds when looking at toys or people?
1. Does your baby chuckle softly?
2. After you have been out of sight, does your baby smile or get excited when he sees you?
3. Does your baby stop crying when she hears a voice other than yours?
4. Does your baby make high-pitched squeals?
5. Does your baby laugh?
6. Does your baby make sounds when looking at toys or people?
Yes
Sometimes
Not yet
Yes
Sometimes
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Yes
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Yes
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Yes
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Yes
Sometimes
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12
GROSS MOTOR
Yes
Sometimes
Not yet
1. While your baby is on his back, does he move his head from side to side?
2. 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?
3. When your baby is on his tummy, does he hold his head up so that his chin is about 3 inches from the floor for at least 15 seconds?
4. When your baby is on her tummy, does she hold her head straight up, looking around? (She can rest on her arms while doing this.)
5. When you hold him in a sitting position, does your baby hold his head steady?
6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?
1. While your baby is on his back, does he move his head from side to side?
2. 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?
3. When your baby is on his tummy, does he hold his head up so that his chin is about 3 inches from the floor for at least 15 seconds?
4. When your baby is on her tummy, does she hold her head straight up, looking around? (She can rest on her arms while doing this.)
5. When you hold him in a sitting position, does your baby hold his head steady?
6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
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Yes
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Yes
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Yes
Sometimes
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13
FINE MOTOR
Yes
Sometimes
Not yet
1. Does your baby hold his hands open or partly open (rather than in fists, as they were when he was a newborn)?
2. When you put a toy in her hand, does your baby wave it about, at least briefly?
3. Does your baby grab or scratch at his clothes?
4. When you put a toy in her hand, does your baby hold onto it for about 1 minute while looking at it, waving it about, or trying to chew it?
5. Does your baby grab or scratch his fingers on a surface in front of him, either while being held in a sitting position or when he is on his tummy?
6. When you hold your baby in a sitting position, does she reach for a toy on a table close by, even though her hand may not touch it?
1. Does your baby hold his hands open or partly open (rather than in fists, as they were when he was a newborn)?
2. When you put a toy in her hand, does your baby wave it about, at least briefly?
3. Does your baby grab or scratch at his clothes?
4. When you put a toy in her hand, does your baby hold onto it for about 1 minute while looking at it, waving it about, or trying to chew it?
5. Does your baby grab or scratch his fingers on a surface in front of him, either while being held in a sitting position or when he is on his tummy?
6. When you hold your baby in a sitting position, does she reach for a toy on a table close by, even though her hand may not touch it?
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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14
PROBLEM SOLVING
Yes
Sometimes
Not yet
1. 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 his eyes, sometimes turning his head?
2. 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 her eyes?
3. When you hold your baby in a sitting position, does he look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of him?
4. When you put a toy in her hand, does your baby look at it?
5. When you put a toy in his hand, does your baby put the toy in his mouth?
6. When you dangle a toy above your baby while she is lying on her back, does your baby wave her arms toward the toy?
1. 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 his eyes, sometimes turning his head?
2. 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 her eyes?
3. When you hold your baby in a sitting position, does he look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of him?
4. When you put a toy in her hand, does your baby look at it?
5. When you put a toy in his hand, does your baby put the toy in his mouth?
6. When you dangle a toy above your baby while she is lying on her back, does your baby wave her 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 watch his hands?
2. When your baby has her hands together, does she play with her fingers?
3. When your baby sees the breast or bottle, does he seem to know he is about to be fed?
4. Does your baby help hold the bottle with both hands at once, or when nursing, does she hold the breast with her free hand?
5. Before you smile or talk to your baby, does he smile when he sees you nearby?
6. When in front of a large mirror, does your baby smile or coo at herself?
1. Does your baby watch his hands?
2. When your baby has her hands together, does she play with her fingers?
3. When your baby sees the breast or bottle, does he seem to know he is about to be fed?
4. Does your baby help hold the bottle with both hands at once, or when nursing, does she hold the breast with her free hand?
5. Before you smile or talk to your baby, does he smile when he sees you nearby?
6. When in front of a large mirror, does your baby smile or coo at herself?
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
Not yet
Yes
Sometimes
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16
1. Does your baby use both hands and both legs equally well? If no, explain:
*
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Yes
No
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17
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18
When you help your baby stand, are his feet flat on the surface most of the time? If no, explain:
*
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Yes
No
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19
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20
Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:
*
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Yes
No
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21
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22
4. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:
*
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Yes
No
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23
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24
5. Do you have concerns about your baby’s vision? If yes, explain:
*
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Yes
No
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25
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26
6. Has your baby had any medical problems in the last several months? If yes, explain:
*
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Yes
No
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27
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28
7. Do you have any concerns about your baby’s behavior? If yes, explain:
*
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Yes
No
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29
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30
8. Does anything about your baby worry you? If yes, explain:
*
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Yes
No
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31
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32
COMMUNICATION SCORE
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33
COMMUNICATION 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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34
GROSS MOTOR SCORE
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35
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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36
FINE MOTOR SCORE
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37
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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38
PROBLEM SOLVING SCORE
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39
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
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40
PERSONAL-SOCIAL SCORE
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41
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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