• 39-44 Month Questionnaire

    39 months 0 days through 44 months 30 days

  • On the following pages are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please fill in the circle that indicates whether your child is doing the activity regularly, sometimes, or not yet.

  • Child Information

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  • Important Points to Remember:

    • Try each activity with your child before making a response
    • Make completing this questionnaire a game that is fun for you and your child.
    • Make sure your child is rested and fed.

  • COMMUNICATION

  • 1. Without giving your child help by pointing or using gestures, ask him to put the book on the table" and "put the shoe under the chair." Does your child carry out both of these directions correctly?*
  • 2. When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, "barking," "running," "eating," or "crying")? You may ask, "What is the dog (or boy) doing?*
  • 3. Show your child how a zipper on a coat moves up and down, and say, "See, this goes up and down." Put the zipper to the middle, and ask your child to move the zipper down. Return the zipper to the middle, and ask your child to move the zipper up. Do this several times, placing the zipper in the middle before asking your child to move it up or down. Does your child consistently move the zipper up when you say "up" and down when you say "down"?*
  • 4. When you ask, "What is your name?" does your child say both her first and last names?*
  • 5. Without your giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down," or "Give me the pen, open the book, and stand up."*
  • 6. Does your child use all of the words in a sentence (for example, "a," "the," "am," "is," and "are") to make complete sentences, such as "l am going to the park," or "Is there a toy to play with?" or "Are you coming, too?"*

  • GROSS MOTOR

  • 1. Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) He may hold onto the railing or wall. (You can 100k for this at a store, on a playground, or at home.)*
  • 2. Does your child stand on one foot for about 1 second without holding onto anything?*
  • 3. While standing, does your child throw a ball overhand by raising his arm to shoulder height and throwing the ball forward? (Dropping the ball or throwing the ball underhand should be scored as "not yet".)*
  • 4. Does your child jump forward at least 6 inches with both feet leaving the ground at the same time?*
  • 5. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)*
  • 6. Does your child climb the rungs of a ladder of a playground slide and slide down without help?*

  • FINE MOTOR

  • 1. After your child watches you draw a single circle with a pencil, crayon, or pen, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?*
  • 2. After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction?*
  • 3. Does your child try to cut paper with child-safe scissors? He does not need to cut the paper but must get the blades to open and close while holding the paper with the other hand. (You may show your child how to use scissors. Carefully watch your child's use of scissors for safety reasons.)*
  • 4. When drawing, does your child hold a pencil, crayon, or pen between her fingers and thumb like an adult does?*
  • 5. Does your child put together a five-to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)*
  • 6. Using the shape at right to look at, does your child copy it onto a large piece of paper using a pencil, crayon, or pen, without tracing? (Your child's drawing should look like the design of the shape, except it may be different in size.)*

  • PROBLEM SOLVING

  • 1. When you point to the figure and ask your child, "What is this?" does your child say a word that means a person or something similar? (Mark "yes" for responses like "snowman, "boy," "man," "girl," "Daddy," "spaceman," and "monkey. ")*
  • 2. When you say, "Say 'seven three,'" does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, "Say 'eight two."' (Your child must repeat just one series of two numbers for you to answer "yes" to this question.)*
  • 3. Show your child how to make a bridge with blocks, boxes, or cans, like the example. Does your child copy you by making one like it?*
  • 4. When you say, "Say 'five eight three,'" does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, "Say 'six nine two."' (Your child must repeat just one series of three numbers for you to answer yes" to this question.)*
  • 5. When asked, "Which circle is the smallest?" does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)*
  • 6. Does your child dress up and "play-act," pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother or sister, or an imaginary animal or figure.*

  • PERSONAL-SOCIAL

  • 1. When he is looking in a mirror and you ask, "Who is in the mirror?" does your child say either "me" or his own name?*
  • 2. Does your child put on a coat, jacket, or shirt by herself?*
  • 3. Using these exact words, ask your child, "Are you a girl or a boy?" Does your child answer correctly?*
  • 4. Does your child take turns by waiting while another child or adult takes a turn?*
  • 5. Does your child serve himself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?*
  • 6. Does your child wash his hands using soap and water and dry off with a towel without help?*

  • OVERALL

  • 1. Do you think your child hears well?*
  • 2. Do you think your child talks like other children her age?*
  • 3. Can you understand most of what your child says?*
  • 4. Can other people understand most of what your child says?*
  • 5. Do you think your child walks, runs and climbs like other children her age?*
  • 6. Does either parent have a family history of childhood deafness or hearing impairment?*
  • 7. Do you have any concerns about your child's vision?*
  • 8. Has you child had any medical problems in the last several months?*
  • 9. Do you have any concerns about your child's behavior?*
  • 10. Does anything about your child worry you?*

  • M-CHAT-RTM (Modified Checklist for Autism in Toddlers Revised)

    Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no. Please mark yes or no for every question. Thank you very much.
  • 1. If you point at something across the room, does your child look at it?
  • 2. Have you ever wondered if your child might be deaf?
  • 3. Does your child play pretend or make-believe?
  • 4. Does your child like climbing on things?
  • 5. Does your child make unusual finger movements near his or her eyes?
  • 6. Does your child point with one finger to ask for something or to get help?
  • 7. Does your child point with one finger to show you something interesting?
  • 8. Is your child interested in other children?
  • 9. Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share?
  • 10. Does your child respond when you call his or her name?
  • 11. When you smile at your child, does he or she smile back at you?
  • 12. Does your child get upset by everyday noises?
  • 13. Does your child walk?
  • 14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her?
  • 15. Does your child try to copy what you do?
  • 16. If you turn your head to look at something, does your child look around to see what you are looking at?
  • 17. Does your child try to get you to watch him or her?
  • 18. Does your child understand when you tell him or her to do something?
  • 19. If something new happens, does your child look at your face to see how you feel about it?
  • 20. Does your child like movement activities?

  • Childhood Lead Risk Questionnaire

    ALL CHILDREN 6 MONTHS THROUGH 6 YEARS OF AGE MUST BE EVALUATED FOR LEAD POISONING

  • A blood lead test should be performed on children:

    • with any “Yes” or “Don’t Know” response
    • living in a high-risk ZIP code area
    • all Medicaid-eligible children should have a blood lead test prior to 12 months of age and 24 months of age. If a Medicaid-eligible child between 36 months and 72 months of age has not been previously tested, a blood lead test should be performed.

    If responses to all the questions are “No”:

    • re-evaluate at every well child visit or more often if deemed necessary
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  • Respond to the following questions by selecting the appropriate answer.

  • 1. Is this child eligible for or enrolled in Medicaid, Head Start, All Kids or WIC?
  • 2. Does this child have a sibling with a blood lead level of 10 mcg/dL or higher?
  • 3. Does this child live in or regularly visit a home built before 1978?
  • 4. In the past year, has this child been exposed to repairs, repainting or renovation of a home built before 1978?
  • 5. Is this child a refugee or an adoptee from any foreign country?
  • 6. Has this child ever been to Mexico, Central or South America, Asian countries (i.e., China or India), or any country where exposure to lead from certain items could have occurred (for example, cosmetics, home remedies, folk medicines or glazed pottery)?
  • 7. Does this child live with someone who has a job or a hobby that may involve lead (for example, jewelry making, building renovation or repair, bridge construction, plumbing, furniture refinishing, or work with automobile batteries or radiators, lead solder, leaded glass, lead shots, bullets or lead fishing sinkers)?
  • 8. At any time, has this child lived near a factory where lead is used (for example, a lead smelter or a paint factory)?
  • 9. Does this child reside in a high-risk ZIP code area?

  • If there is any “Yes” or “Don’t Know” response; and

    • the child has proof of two consecutive blood lead test results (documented below) that are each less than 10 mcg/dL (with one test at age 2 or older), and
    • there has been no change in the child’s living conditions, a blood lead test is not needed at this time
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  • PEDIATRIC TB RISK ASSESSMENT FORM

  • Format: (000) 000-0000.
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  • Sex:
  • Hispanic:
  • Race:
  • US Born:
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  • Format: (000) 000-0000.

  • TB Risk Factors:

  • 1. Does the child have any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss or fatigue) or an abnormal chest X-ray?
  • 2. In the last 2 years, has the child lived with or spent time with someone who has been sick with TB?
  • 3. Was the child born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East?
  • 4. Has the child lived or traveled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East for more than one month?
  • 5. Have any members of the child's household come to the United States from another country?
  • 6. Is the child exposed to a person who: Is currently in jail or who has been in jail in the past 5 years? Has HIV? Is homeless? Lives in a group home? Uses illegal drugs? Is a migrant farm worker?
  • 7. Is the child/teen in jail or ever been in jail?
  • 8. Does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression?

  • If yes, to any of the above, the child has an increased risk of TB infection and should have a TST/IGRA.

    All children with a positive TST/IGRA result must have a medical evaluation, including a chest X ray. Treatment for latent TB infection should be initiated if the chest X-ray is normal and there are no signs of active TB. If testing was done, please attach or enter results on next page.

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