Child's Name
*
First Name
Last Name
Today's Date
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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 point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, “What is this?” does your child correctly name at least one picture?
2. Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions? a. “Put the toy on the table.” d. “Find your coat.” b. “Close the door.” e. “Take my hand.” c. “Bring me a towel.” f. “Get your book.”
3. When you ask your child to point to her nose, eyes, hair, feet, ears, andso forth, does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark “sometimes” if she correctly points to at least three different body parts.)
4. Does your child say 15 or more words in addition to “Mama” and “Dada”?
5. Does your child correctly use at least two words like “me,” “I,” “mine,” and “you”?
6. Does your child say two or three words that represent different ideas together, such as “See dog,” “Mommy come home,” or “Kitty gone”? (Don’t count word combinations that express one idea, such as “byebye,” “all gone,” “all right,” and “What’s that?”)
Please give an exampleof your child’s word combinations:
Please give an exampleof your child’s word combinations:
GROSS MOTOR
*
Yes
Sometimes
Not yet
1. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (If your child already kicks a ball, mark “yes” for this item.)
2. Does your child run fairly well, stopping herself without bumping into things or falling?
3. Does your child walk down stairs if you hold onto one of his hands? He may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
4. Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wall.
5. Does your child jump with both feet leaving the floor at the same time?
6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward
FINE MOTOR
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Yes
Sometimes
Not yet
1. Does your child get a spoon into her mouth right side up so that the food usually doesn’t spill?
2. Does your child stack six small blocks or toys on top of each other by himself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)
3. Does your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?
4. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)
5. Does your child flip switches off and on?
6. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
PROBLEM SOLVING
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Yes
Sometimes
Not yet
1. Without your showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)?
2. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up at least two blocks side by side? (You can also use
spools of thread, small boxes, or other toys.)
3. Does your child pretend objects are something else? For example, does your child hold a cup to his ear, pretending it is a telephone? Does he put a box on his head, pretending it is a hat? Does he use a block or small toy to stir food?
4. After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark “not yet” if your child scribbles back and forth.)
5. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump out the crumb or Cheerio? (Do not show her how.) (You can use a soda-pop bottle or a baby bottle.)
6. If you give your child a bottle, spoon, or pencil upside down, does he turn it right side up so that he can use it properly?
PERSONAL-SOCIAL
*
Yes
Sometimes
Not yet
1. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?
2. If you do any of the following gestures, does your child copy at least one of them? a. Open and close your mouth. b. Blink your eyes. c. Pull on your earlobe. d. Pat your cheek.
3. Does your child eat with a fork?
4. Does your child drink from a cup or glass, putting it down again with
little spilling?
5. When playing with either a stuffed animal or a doll, does your child pretend
to rock it, feed it, change its diapers, put it to bed, and so forth?
6. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she cannot turn?
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::
*
Yes
No
3. When your baby is standing, are her feet flat on the surface most of the time?If no, explain:
*
Yes
No
4.. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:
*
Yes
No
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:
*
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:
*
Yes
No
8. Do you have any concerns about your baby’s behavior? 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 15-25 close to expected and needs additional learning activities and follow-up >25 Above expected and development appears to be on schedule
GROSS MOTOR SCORE
GROSS MOTOR SCORE
< 25 below expected and needs assessment and follow-up 25-40 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
< 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
PROBLEM SOLVING SCORE
PROBLEM SOLVING 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
PERSONAL-SOCIAL SCORE
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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