4 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.
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Email *
CHILD'S NAME *
PARENTS NAME COMPLETING FORM *
COMMUNICATION *
YES
SOMETIMES
NOT YET
Does your baby chuckle softly?
After you have been out of sight, does your baby smile or get excited when he sees you?
Does your baby stop crying when she hears a voice other than yours?
Does your baby make high-pitched squeals?
Does your baby laugh?
Does your baby make sounds when looking at toys or people?
GROSS MOTOR *
YES
SOMTIMES
NOY YET
While your baby is on his back, does he move his head from side to side?
After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?
When your baby is on his tummy, does he hold his head up so that his chin is about 3 in. from the floor for at least 15 sec.?
When your baby is on her tummy, does she hold her head straight up, looking around?
When you hold him in a sitting position, does your baby hold his head steady?
While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?
FINE MOTOR *
YES
SOMETIMES
NOT YET
Does your baby hold his hands open or partly open when he is awake?
When you put a toy in his hand, does your baby hold it in his hand briefly?
Does your baby grab or scratch at her clothes?
When you put a toy in her hand, does your baby hold onto it for about 1 min. while looking at it, waving it about, or trying to chew it?
Does your baby grab or scratch his fingers on a surface in front of him, either while being held in a sitting position or when he is on his tummy?
When you hold your baby in a sitting position, does she reach for a toy on a table close by, even though her hand may not touch it?
PROBLEM SOLVING *
YES
SOMETIMES
NOT YET
When you move a toy slowly from side to side in front of your baby's face, does your baby follow the toy with her eyes, sometimes turning her head?
When you move a small toy up and down slowly in front of your baby's face, does your baby follow the toy with his eyes?
When you hold your baby in a sitting position, does she look at a toy that you place on the table or floor in front of her?
When you put a toy in her hand, does your baby look at it?
When you put a toy in his hand, does your baby put the toy in his mouth?
When you dangle a toy about your baby while she is lying on her back, does your baby wave her arms toward the toy?
PERSONAL-SOCIAL *
YES
SOMETIMES
NOT YET
Does your baby watch his hands?
When your baby has her hands together, does she play with her fingers?
When your baby sees the breast or bottle, does she seem to know she is about to be fed?
Does your baby help hold the bottle with both hands at once, or when nursing, does she hold the breast with her free hand?
Before you smile or talk to your baby, does he smile when he sees you nearby?
When in front of a large mirror, does your baby smile or coo at herself?
OVERALL *
YES
NO
Does your baby move both hands and both legs equally well? If no, explain below:
When you help your baby stand, are his feet flat o n the surface most of the time? If no, explain below:
Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, 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 baby's vision? If yes, explain below:
Has your baby had any medical problems in the last several months? If yes, explain below:
Do you have concerns about your baby's behavior? If yes, explain below:
Does anything about your baby worry you? If yes, explain below:
If you answered "NO" to OVERALL questions #1 an #2, please explain below.
If you answered "YES" to OVERALL questions #3, #4, #5, #6, #7, #8 please explain below.
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