Childs Information
Childs First Name
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Childs Middle Initial
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Childs Last Name
*
Childs Date of Birth
*
Childs Gender
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Male
Female
Person filling out questionnaire
Parent/Guardian
First Name
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Middle Initial
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Last Name
*
Street Address
*
City
*
State/province
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ZIP/postal Code
*
Country
*
Home Phone Number
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Cell/other Phone Number
Email
*
example@example.com
Relationship to child
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Parent
Guardian
Teacher
Other (please fill out field adjacent)
Grandparent/relative
Foster parent
Child Care Provider
Other
Person(s) assisting in questionnaire completion
36 Month Questionnaire
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Rows
Often or Always
Sometimes
Rareley or Never
Check if this is a concern
Does your child look at you when you talk to him/her?
Does your child like to be hugged or cuddled?
Does your child talk or play with adults he/she knows well?
Does your child cling to you more than you expect?
When upset, does your child calm down within 15 minutes?
Does your child seem too friendly with strangers?
Does your child settle her/himself down after exciting activities?
Does your child move from one activity to the next with little difficulty? (for example, from playtime to mealtime)
Does your child seem happy?
Is your child interested in things around him/her, such as people, toys, and foods?
Does your child do what you ask her/him to do?
Does your child seem more active than other children his/her age?
Does your child stay with activities he/she enjoys for at least 5 minutes? (other than watching shows or videos, or playing with electronics)
Do you and your child enjoy mealtimes together?
15. Does your child have eating problems? for example, does he/she stuff food, vomit, eat things that are not food, or _______? (please describe in the box below)
Does your child sleep at least 8 hours in a 24-hour period?
Does your child use words to tell you what he/she wants or needs?
Does your child follow routine directions? For example, does he/she come to the table or help clean up his/her toys when asked?
Does your child check to make sure you are near when exploring new places, such as a park or a friends house?
21. Does your child do things over and over and get upset when you try to stop him/her? For example, does she rock, flap her hands, spin, or ________________? (please describe in the box below)
Does your child hurt him/herself on purpose?
Does your child stay away from dangerous things, such as fire or a moving car?
Does your child destroy or damage things on purpose?
Does your child use words to describe her feelings and the
feelings of others? For example, does he/she say, "I'm happy," "I don't like that," or "She's sad"?
Can your child name a friend?
Do other children like to play with your child?
Does your child like to play with other children?
Does your child try to hurt other children, adults, or animals? (For example, by kicking or biting)
Does your child show an unusual interest in or knowledge of sexual language and activity?
Does you child try to show you things by pointing at them and looking back at you?
Does your child pretend objects are something else? (For example, does he/she pretend a banana is a phone)
Does your child wake three or more times during the night?
34. Is your child too fearful? If "sometimes" or "often or always" please describe in the box below.
35. Has anyone shared concerns about your child's behaviors? If "sometimes" or "often or always" Please explain in the box below.
Please describe from question 15
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Please describe from question 21
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Please describe from question 34
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Please describe from question 35
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Overall
Use the space below for additional comments
Do you have concerns about your child's eating, sleeping, or toileting habits? If yes, please explain below
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Yes
No
If yes, please explain
Does anything about your child worry you? If yes, Please explain below
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Yes
No
If yes, please explain
What do you enjoy about your child?
*
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