36 MONTH QUESTIONNAIRE
On the following pages are questions about activities babies may do.  Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet.  For each item, please fill in the the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.
Sign in to Google to save your progress. Learn more
Email *
CHILD'S NAME *
PARENTS NAME COMPLETING FORM *
COMMUNICATION *
YES
SOMETIMES
NOT YET
When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts?
Does your child make sentences that are three or four words long?
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?
When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture? You may ask, "What is the dog doing?"
Show your child how a zipper on a coat moves up and does, and say "See , this goes up and down." Put the zipper to the middle and ask your child to move the zipper down. Does your child consistently move the zipper up when you say "up" and down when you say "down"?
When you ask, "What is your name?" does your child say both her first and last names?
GROSS MOTOR *
YES
SOMTIMES
NOY YET
Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
Does your child jump with both feet leaving the floor at the same time?
Does your child walk up stairs, using only one foot on each stair?
Does your child stand on one foot for about 1 sec. without holding onto anything?
While standing, does your child throw a ball overhand by raising his arm to shoulder height and throwing the ball forward?
Does your child jump forward at least 6 in. with both feet leaving the ground at the same time?
FINE MOTOR *
YES
SOMETIMES
NOT YET
After your child watches you draw a line from the top of the paper to the bottom, ask him 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 vertical direction?
Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace?
After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?
After your child watches you draw a line from the top of the paper to the bottom, ask him 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?
Does your child try to cut paper with child-safe scissors? Mark yes, even if he just opens and closes the blades.
When drawing, does your child hold a pencil or crayon between her fingers and thumb like an adult does?
PROBLEM SOLVING *
YES
SOMETIMES
NOT YET
While your child watches, line up four objects like blocks or cars in a row. Does your child copy you?
If your child wants something she cannot reach, does she find a chair or box to stand on to reach it?
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?
When you say "Say 'seven three,'" does your child repeat just the two numbers in the same order?
Show your child how to make a bridge with blocks, boxes, or cans. Does your child copy you by making one like it?
When you say, "Say 'five eight three,'" does your child repeat just the three numbers in the same order?
PERSONAL-SOCIAL *
YES
SOMETIMES
NOT YET
Does your child use a spoon to feed himself with little spilling?
Does your child push a wagon, stroller, or other toy on wheels, steering it around objects and backing out of the corners if he cannot turn?
When your child is looking in a mirror and you ask, "who is in the mirror?" does he say either "me" or his own name?
Does your child put on a coat, jacket, or shirt on by himself?
Using these exact words, ask your child, "Are you a girl or a boy?" Does your child answer correctly?
Does your child take turns by waiting while another child or adult takes a turn?
OVERALL *
YES
NO
Do you think your child hears well? If no, explain below:
Do you think your child talks like other toddlers his age? If no, explain below:
Can you understand most of what your child says? If no, explain below:
Can other people understand most of what your child says? If no, explain below:
Do you think your child walks, runs, and climbs like other toddlers her age? If no, explain below:
Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain below:
Do you have concerns about your child's vision? If yes, explain below:
Has your child had any medical problems in the last several months? If yes, explain below:
Do you have any concerns about your child's behavior? If yes, explain below?
Does anything about your child worry you? If yes, explain below:
If you answered "NO" to OVERALL questions #1, #2, #3, #4 or #5 please explain below.
If you answered "YES" to OVERALL questions #6, #7, #8, #9 or #10 please explain below.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms