Pediatric Case History Language (Birth to 24 Months)
Please choose yes or no, and fill out the blanks provided where appropriate.
Child's Name
*
First Name
Last Name
Does your child:
*
Yes
No
Enjoy your attention?
React to sounds in the environment?
Turn to find out what made the sound?
Put toys or objects in his or her mouth?
Shake or bang toys?
Stop activity when his/her name is called?
Look toward something that you point to or call attention to?
Seem to understand when you hold out your hand and say "come here"?
Stop activity when told "no no"?
Understand: "Look"
Understand: "Give me a kiss"
Understand: "Wave bye-bye"
Play with two objects at once (like a baby and a bottle, two cars)?
Follow simple directions such as "throw me the ball" or "give me your bottle" when you point or hold out your hand?
Play appropriately with a ball?
Play appropriately with blocks?
Play appropriately with a spoon/cup?
Play appropriately with a car/train?
Play appropriately with a baby doll?
Give you the correct simple objects that you ask for, such as a cup, bottle, ball, car, blanket, etc.
Point to simple pictures of familiar and simple objects in a book?
Point to his/her body parts when asked, "show me your___"?
List body parts your child knows:
Please check beside each phrase that you know for sure your child understands:
Are you hungry?
Are you sleepy?
Be careful.
Come here.
Don't touch.
Give it to Mommy.
Go get ____.
Let's go bye-bye.
Sit down.
Stop it.
Be quiet.
Clap your hands.
Change diaper.
Don't do that.
Get up.
Give me a hug.
Be still.
Open your mouth.
Spit it out.
Time to go nite-nite.
How does your child let you know that he/she is hungry or want a specific snack?
How does your child let you know that he does not want something?
How does your child get attention?
Does your child:
*
Yes
No
Exhibit different types of cries that mean different things?
Make cooing or gurgling sounds?
Make grunts or discomfort sounds other than crying?
Babble or gurgle when you talk or play with her/him?
vocalize 2 different vowel sounds?
vocalize 2 different consonant sounds?
vocalize 2 sounds to form a syllable?
Have a way to get your attention?
Play simple games like "peek-a-boo" or hiding things?
Use pushing or pulling to get what he/she wants?
Use eye contact when he/she plays?
Play with someone for up to a minute?
Babble with 2 syllables together (mama,baba,dada)?
Use consonants?
Hold out a toy to show it to you?
Imitate words or parts of phrases that he/she has just overheard?
Imitate animal sounds?
"sing" along with music?
Ask for more?
How does your child get attention?
Which consonants does your child know?
List up to 20 words your child can say. If he/she can say over 20 words, approximately how many words can they say?
Does your child use two-word phrases? Please give examples.
Submit
Should be Empty: