Child's Name
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First Name
Last Name
Today's Date
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Day
-
Month
Year
Date
Date of Birth
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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. Does your baby make two similar sounds, such as “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)
2. If you ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)? you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)?
3. Does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back,” without your using gestures?
4. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)
5. When you ask, “Where is the ball (hat, shoe, etc.)?” does your baby look at the object? (Make sure the object is present. Mark “yes” if she knows one object.)
6. When your baby wants something, does he tell you by pointing to it?
GROSS MOTOR
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Yes
Sometimes
Not yet
1. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?
2. While holding onto furniture, does your baby lower herself with control (without falling or flopping down)?
3. Does your baby walk beside furniture while holding on with only one hand?
4. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark “yes” for this item.)
5. When you hold one hand just to balance your baby, does she take several steps forward? (If your baby already walks alone, mark “yes” for this item.)
6. Does your baby stand up in the middle of the floor by himself and take several steps forward?
FINE MOTOR
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Yes
Sometimes
Not yet
1. After one or two tries, does your baby pick up a piece of string with his first finger and thumb? (The string may be attached to a toy.)
2. Does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger? She may rest her arm or hand on the table while doing it.
3. Does your baby put a small toy down, without dropping it, and then take his hand off the toy?
4. Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?
5. Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)
6. Does your baby help turn the pages of a book? (You may lift a page for him to grasp.)
PROBLEM SOLVING
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Yes
Sometimes
Not yet
1. When holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?
2. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?
3. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.)
4. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although she may not let go of it? (If she already lets go of the toy into a bowl or box, mark “yes” for this item.)
5. Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show him how to do it.)
6. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If she already scribbles on her own, mark “yes” for this item.)
PERSONAL-SOCIAL
*
Yes
Sometimes
Not yet
1. When you hold out your hand and ask for his toy, does your baby offer it to you even if he doesn’t let go of it? (If he already lets go of the toy into your hand, mark “yes” for this item.)
2. When you dress your baby, does she push her arm through a sleeve once her arm is started in the hole of the sleeve?
3. When you hold out your hand and ask for his toy, does your baby let go of it into your hand?
4. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?
5. Does your baby roll or throw a ball back to you so that you can return it to him?
6. Does your baby play with a doll or stuffed animal by hugging it?
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. Does your baby play with sounds or seem to make words? If no, explain::
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Yes
No
3. When your baby is standing, are her feet flat on the surface most of the time?If no, explain:
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Yes
No
4.. 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
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:
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Yes
No
6. Do you have concerns about your baby’s vision? If yes, explain:
*
Yes
No
7. Has your baby had any medical problems in the last several months? If yes, explain:
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Yes
No
8. Do you have any concerns about your baby’s behaviour? If yes, explain:
*
Yes
No
9. Does anything about your baby worry you? If yes, explain:
*
Yes
No
COMMUNICATION SCORE
COMMUNICATION SCORE
< 15 below expected and needs assessment and follow-up 15-30 close to expected and needs additional learning activities and follow-up >30 Above expected and development appears to be on schedule
GROSS MOTOR SCORE
GROSS MOTOR SCORE
< 20 below expected and needs assessment and follow-up 20-35 close to expected and needs additional learning activities and follow-up >35 Above expected and development appears to be on schedule
FINE MOTOR SCORE
FINE MOTOR SCORE
< 35 below expected and needs assessment and follow-up 35-40 close to expected and needs additional learning activities and follow-up >40 Above expected and development appears to be on schedule
PROBLEM SOLVING SCORE
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
PERSONAL-SOCIAL SCORE
PERSONAL-SOCIAL SCORE
< 20 below expected and needs assessment and follow-up 20-30 close to expected and needs additional learning activities and follow-up >30Above expected and development appears to be on schedule
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