Childs First Name
*
Childs Middle Initial
*
Childs Last Name
*
Childs Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Name
*
First Name
Last Name
Middle Initial
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell/other Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship to child
*
Parent
Guardian
Teacher
Grandparent/relative
Foster Parent
Child care provider
Other
People assisting in the questionnaire completion
60 Month Questionnaire
*
Rows
Often or Always
Sometimes
Rarely or Never
Check if this is a concern
Does your child look at you when you talk to him/her?
Does your child cling to you more than you expect?
Does yor child like to be hugged or cuddled?
Does your child talk or play with adults he/she knows well?
When upset, can your child calm down within 15 minutes?
Does your child seem too friendly with strangers?
Does your child settle him/herself down after exciting activities?
Does your child seem happy?
Does your child cry, scream, or have tantrums for long periods of time?
Is your child interested in things around him/her, such as people, toys, and foods?
Does your child go to the bathroom by him/herself? (Reminders and help with wiping are okay)
12. Does your child have eating problems? for example, does he/she stuff food, vomit, eat things that are not food or _____? (Please describe)
Does your child stay with activities he/she enjoys for at least 15 minutes? (other than watching shows or videos, or playing with electronics)
Do you and your child enjoy mealtimes togather?
Does your child do what you ask him/her to do? for example, he/she wash his/her hands or wait to take a turn when asked?
Does your child seem more active than other children his/her age?
Does your child sleep at least 8 hours in a 24 hour period?
Does your child use words to tell you what he/she needs?
Does your child use words to describe his/her feelings and the feelings of the others? For example, does he/she say "i'm happy". "i dont like that", or "she's sad"?
Does your child move from one activity to the next with little difficulty (for example, from playtime to mealtime)
Does your child explore new places, such as a park or a friends home?
22. Does your child do things over and over and get upset when you try to stop him? For example, does he/she rock, flap their hands, spin, or _____? (please describe below)
Does your child hurt him/herself on purpose?
Does your child follow rules at home or at child care?
Does your child damage or destroy things on purpose?
Does your child stay away from dangerous things, such as fire and moving cars?
Does your child show concern for other people's feelings? for example, does he/she look sad when someones sad?
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 take turnes and share playing with other children?
Does your child show an unusual interest in or knowledge of sexual language or activity?
Does your child wake three or more times during the night?
34. Is your child too worries or fearful? if sometimes or often or always. please describe below.
Does your child have simple back and forth conversation with you?
36. Has anyone shared concerns about your child's behaviors? If sometimes or often or always, please describe below?
Please describe from question 12
Please describe from question 22
Please describe from question 34
Please describe from question 36
Overall
Use the space below to add additional comments
Do you have concerns about your childs eating, sleeping, or toileting habits? If yes, please explain
*
Yes
No
If yes, please explain
Does anything worry you about your child? If yes, please explain
*
Yes
No
If yes, please explain
What do you enjoy about your child?
*
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