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. 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.”
2. 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?
3. When you ask her to point to her nose, eyes, hair, feet, ears, and so forth, does your child 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 correctly use at least two words like “me,” “I,” “mine,” and “you”?
5. Without giving your child help by pointing or using gestures, ask him to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly?
6. Does your child make sentences that are three or four words long? Please give an example:
Please give an exampleof your child’s word combinations:
GROSS MOTOR
*
Yes
Sometimes
Not yet
1. Does your child walk either up or down at least two steps by himself? He may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
2. Does your child run fairly well, stopping herself without bumping into things or falling?
3. Does your child jump with both feet leaving the floor at the same time?
4. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
5. Does your child jump forward at least 3 inches with both feet leaving the ground at the same time?
6. Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall.
FINE MOTOR
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Yes
Sometimes
Not yet
1. 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?
2. Does your child flip switches off and on?
3. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction?
4. Does your child stack seven small blocks or toys on top of each other by herself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)
5. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
6. After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction?
PROBLEM SOLVING
*
Yes
Sometimes
Not yet
1. 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 her head, pretending it is a hat? Does he use a
block or small toy to stir food?
2. Does your child put things away where they belong? For example, does she know her toys belong on the toy shelf, her blanket goes on her
bed, and dishes go in the kitchen?
3. When looking in the mirror, ask “Where is _______?” (Use your child’s name.) Does your child point to his image in the mirror?
4. If your child wants something she cannot reach, does she find a chair or box to stand on to reach it (for example, to get a toy on a counter or to “help” you in the kitchen)?
5. 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 four objects in a row? (You can also use spools of thread, small boxes, or other toys.)
6. When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”) Please write your child’s response here:
Response
PERSONAL-SOCIAL
*
Yes
Sometimes
Not yet
1. If you do any of the following gestures, does your child copy at least one of them? a. Open and close your mouth. c. Pull on your earlobe. b. Blink your eyes. d. Pat your cheek.
2. Does your child eat with a fork?
3. 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?
4. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if he cannot turn?
5. Does your child call herself “I” or “me” more often than her own name? For example, “I do it” more often than “Juanita do it.”
6. Does your child put on a coat, jacket, or shirt by himself?
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
< 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
GROSS MOTOR SCORE
GROSS MOTOR SCORE
< 25 below expected and needs assessment and follow-up 25-45 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
< 20 below expected and needs assessment and follow-up 20-30 close to expected and needs additional learning activities and follow-up >30 Above expected and development appears to be on schedule
PROBLEM SOLVING SCORE
PROBLEM SOLVING SCORE
< 25 below expected and needs assessment and follow-up 25-40 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
< 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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