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Questionnaire
32
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
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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. 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.” b. “Close the door.” c. “Bring me a towel.” d. “Find your coat.” e. “Take my hand.” f. “Get your book.”
3. When you ask your child to point to her nose, eyes, hair, feet, ears, and so 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. 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?
5. When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, “barking,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?”
4. Does your child make sentences that are three or four words long? Please give an example:
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.” b. “Close the door.” c. “Bring me a towel.” d. “Find your coat.” e. “Take my hand.” f. “Get your book.”
3. When you ask your child to point to her nose, eyes, hair, feet, ears, and so 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. 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?
5. When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, “barking,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?”
4. Does your child make sentences that are three or four words long? Please give an example:
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12
Please give an exampleof your child’s word combinations:
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13
GROSS MOTOR
Yes
Sometimes
Not yet
1. Does your child run fairly well, stopping herself without bumping into things or falling?
2. 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.)
3. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
4. Does your child jump with both feet leaving the floor at the same time?
5. 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.
6. Does your child stand on one foot for about 1 second without holding onto anything
1. Does your child run fairly well, stopping herself without bumping into things or falling?
2. 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.)
3. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
4. Does your child jump with both feet leaving the floor at the same time?
5. 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.
6. Does your child stand on one foot for about 1 second without holding onto anything
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14
FINE MOTOR
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. 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?
3. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
4. 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?
5. After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?
6. Does your child turn pages in a book, one page at a time?
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. 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?
3. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
4. 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?
5. After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?
6. Does your child turn pages in a book, one page at a time?
Yes
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15
PROBLEM SOLVING
Yes
Sometimes
Not yet
1. When looking in the mirror, ask, “Where is _______?” (Use your child’s name.) Does your child point to her image in the mirror?
2. If your child wants something he cannot reach, does he 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)?
3. 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.)
4. When you say, “Say ‘seven three,’” does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, “Say ‘eight two.’” Your child must repeat just one series of two numbers for you to answer “yes” to this question.
5. After your child draws a “picture,” even a simple scribble, does she tell you what she drew? (You may say, “Tell me about your picture,” or ask, “What is this?” to prompt her.)
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:
1. When looking in the mirror, ask, “Where is _______?” (Use your child’s name.) Does your child point to her image in the mirror?
2. If your child wants something he cannot reach, does he 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)?
3. 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.)
4. When you say, “Say ‘seven three,’” does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, “Say ‘eight two.’” Your child must repeat just one series of two numbers for you to answer “yes” to this question.
5. After your child draws a “picture,” even a simple scribble, does she tell you what she drew? (You may say, “Tell me about your picture,” or ask, “What is this?” to prompt her.)
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:
Yes
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16
Response
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17
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 use a spoon to feed himself with little spilling?
3. 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?
4. Does your child put on a coat, jacket, or shirt by himself?
5. After you put on loose-fitting pants around her feet, does your child pull them completely up to her waist?
6. When your child is looking in a mirror and you ask, “Who is in the mirror?” does he say either “me” or his own name?
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 use a spoon to feed himself with little spilling?
3. 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?
4. Does your child put on a coat, jacket, or shirt by himself?
5. After you put on loose-fitting pants around her feet, does your child pull them completely up to her waist?
6. When your child is looking in a mirror and you ask, “Who is in the mirror?” does he say either “me” or his own name?
Yes
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18
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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19
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20
2. Does your baby play with sounds or seem to make words? If no, explain::
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Yes
No
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21
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22
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
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23
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24
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
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25
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26
5. 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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27
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28
6. Do you have concerns about your baby’s vision? If yes, explain:
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Yes
No
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29
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30
7. 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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31
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32
8. Do you have any concerns about your baby’s behavior? If yes, explain:
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Yes
No
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33
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34
9. Does anything about your baby worry you? If yes, explain:
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Yes
No
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35
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36
COMMUNICATION SCORE
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37
COMMUNICATION 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
GROSS MOTOR SCORE
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39
GROSS MOTOR 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
FINE MOTOR SCORE
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41
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
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42
PROBLEM SOLVING SCORE
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43
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
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44
PERSONAL-SOCIAL SCORE
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45
PERSONAL-SOCIAL SCORE
< 30 below expected and needs assessment and follow-up 30-405 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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