Screening Questionnaire: 1 Year
Scroll down and complete questions for the discipline of your interest
Caregiver's Name
*
First Name
Last Name
Child's Diagnosis (if applicable)
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Contact Method
*
Phone Call
Text
Email
Physical Therapy
Physical Therapy
1. Stands up from being on belly without rom people/furniture
Yes
No
2. Walks without support
Yes
No
3. Tries to kick a large ball while standing
Yes
No
4. Walks sideways or backwards
Yes
No
5. Able to pick up toys from floor while standing and without falling
Yes
No
6. Carries large toys while standing
Yes
No
7. Walks upstairs/downstairs with one hand held by adult
Yes
No
8. Climbs adult chair
Yes
No
9. Throws ball over 3ft
Yes
No
10. Climbs ladder from jungle gyms/slides
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Holds crayons with fingers (answer NO if holding crayon full fisted)
Yes
No
2. Places small items into small containers
Yes
No
3. Plays with toys in the middle of his body
Yes
No
4. Imitates vertical lines and circles
Yes
No
5. Stack blocks and form a 4-block tower
Yes
No
6. Paints/scribbles within paper boundaries
Yes
No
7. Helps turn thick book pages one at a time
Yes
No
8. Can string one large bead
Yes
No
9. Shows toy preferences
Yes
No
10. Expresses affection via hugs and kisses
Yes
No
Additional Occupational Therapy comments or concerns:
Speech Therapy
Speech Therapy
1. What is your child's communication method?
Whines, screams, cries
Simple speech sounds (goo)
Single syllable sounds (da, ma, pa)
Reduplicated babbling (ma-ma, da-da, ba-ba)
Variegated babbling (e.g. mixing different sounds ''ba de da'')
Hand gestures
Single words
Two word combinations (e.g. More milk, Drink juice)
American Sign Language
2. Gives away a toy/food/object when asked to do so
Yes
No
3. Follow simple steps such as "Give me Five!" or "Touch your nose"
Yes
No
4. Gets your attention when you aren't paying attention to an object, pet or toy
Yes
No
5. Points to different objects, or pictures of objects when someone names them
Yes
No
6. Repeats or imitates words heard in conversation
Yes
No
7. Points to basic body parts (hands, feet, head, nose, mouth, eyes)
Yes
No
8. Shows actions when asked to (jump, throw, run, swing)
Yes
No
9. Has about 50 words in vocabulary
Yes
No
10. Feeding concerns
Transitioning from bottle to baby food
Coughs with solids/liquids
Choking or gagging
Reflux
Regurgitation of solids/liquid through nose
Difficulty with chewing
Picky eater
Additional Speech Therapy comments or concerns:
Applied Behavior Analysis
Please describe how your child communicates with you (words, pictures, signs, assistive technology). Example 1: My child can use 50 words to ask for items or activities. Example 2: My child typically pulls me towards the items they want.
Please describe any challenging behaviors your child has exhibited when faced with difficult situations such as but not limited to being told no or asked to complete a non-preferred task. Example 1: When I tell my child that it is time for a bath, they typically run away and refuse to come. Example 2: When my child loses a game, they typically will cry and throw the game pieces.
Please describe the main goals you have for your child.
Submit
Submit
Should be Empty: