Age 2: Screening Questionnaire
Please fill out the sections that are relevant to your child. This will help us gather important information about your child's development.
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. Participates in "Simon says" games (imitates arms up, stomp feet, etc.)
Yes
No
2. Balance in one foot without support for 5 sec.
Yes
No
3. Runs and stops without using hands to slow down
Yes
No
4. Walks backwards
Yes
No
5. Avoids obstacles when walking
Yes
No
6. Jumps in place with both feet
Yes
No
7. Jumps over a distance of 8 in
Yes
No
8. Walks upstairs/downstairs alternating feet
Yes
No
9. Jumps over toys with both feet
Yes
No
10. Climbs jungle gyms and ladders
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Holds crayons with thumb and fingers (answer NO if holding crayon full fisted)
Yes
No
2. Imitates horizontal strokes, and a cross
Yes
No
3. Imitates a 3-block design (if you make a train or a bridge with 3 blocks)
Yes
No
4. Folds paper in half with some accuracy
Yes
No
5. Strings small beads
Yes
No
6. Shows independence by separating easily from parents in familiar environments
Yes
No
7. Takes pride in achievements (cheering self after completing a task/game)
Yes
No
8. Participates in circle games (ring around the rosie, hide and seek)
Yes
No
9. Pulls pants down, unfasten or fasten large buttons.
Yes
No
10. Uses forks accurately or pours down liquids from a small container.
Yes
No
Additional Occupational Therapy comments or concerns:
Speech Therapy
Speech Therapy
1. What is your child's communication method?
Whines, screams, cries
Gestures (e.g. push, pull, grab, wave)
Produces these sounds clearly (p, b, m, k, g, w, h, n, t, d)
American Sign Language
Single words
Two word combinations (e.g. want milk, eat cereal, puppy eat, go bye bye )
Three word Phrases (e.g. Puppy drink water, daddy go park)
2. Has at least 50 words in vocabulary and says at least two new words each week
Yes
No
3. Understands at least 10 objects and 10 actions you talk about or show in pictures (e.g. Where's the bear? Who is dancing?)
Yes
No
4. Uses words such as "I, it, my, me, mine, you" in conversation
Yes
No
5. Follows 2-3 step commands (E.g. Give me your spoon and give mommy your cup)
Yes
No
6. Uses simple modifiers (e.g. dirty, clean, little, big)
Yes
No
7. Understands and verbalizes at least 4 spatial concepts/prepositions (e.g. on, off, in, out, under)
Yes
No
8. Understands negative reasoning (e.g. "no more", "not your" "not a spoon")
Yes
No
9. Answers basic WH questions (e.g. what's that? where is baby? who is that?)
Yes
No
10. Any feeding difficulties?
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
NG, J or G-tube fed
Additional Speech Therapy comments or concerns:
Applied Behavior Analysis
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 section
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