• 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

  • GROSS MOTOR

  • FINE MOTOR

  • PROBLEM SOLVING

  • PERSONAL-SOCIAL

  • OVERALL

  • 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.

  • 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 circling the appropriate answer.

  • 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

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  • TB Risk Factors:

  • 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.

  • Should be Empty: