18 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
When your child wants something, does he tell you by pointing to it?
When you ask her to, does your child go into another room to find a familiar toy or object?
Does your child say eight or more words in addition to "Mama" and "Dada"?
Does your child imitate a two-word sentence? For example, "Mama eat" or "Daddy play".
Without you showing him, does your child point to the correct picture when you say, "Show me the kitty," or ask "Where is the dog?"
Does your child say two or three words that represent different ideas together, such as "See dog," Mommy come home, " or "Kitty gone"?
GROSS MOTOR *
YES
SOMTIMES
NOY YET
Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?
Does your child move around by walking, rather than by crawling on his hands and knees?
Does your child walk well and seldom fall?
Does your child climb on an object such as a chair to reach something he wants?
Does your child walk down stairs if you hold onto one of her hands?
When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it?
FINE MOTOR *
YES
SOMETIMES
NOT YET
Does your child throw a small ball with a forward arm motion?
Does your child stack a small block or toy on top of another one?
Does your child make a mark on the paper with the tip of a crayon?
Does your child stack three small blocks or toys on top of each other by herself?
Does your child turn the pages of a book by himself?
Does your child get a spoon into her mouth right side up so that the food usually doesn't spill?
PROBLEM SOLVING *
YES
SOMETIMES
NOT YET
Does your child drop several small toys, one after another, into a container like a bowl or box?
After you have shown your child how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?
After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle over to dump it our?
Without you showing her how, does your child scribble back and forth when you give her a crayon?
After watching you draw a line from the top of the paper to the bottom with a crayon, does your child copy you by drawing a single line on the paper in any direction?
After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump out the crumb or Cheerio?
PERSONAL-SOCIAL *
YES
SOMETIMES
NOT YET
While looking at herself in the mirror, does your child offer a toy to her own image?
Does your baby play with a doll or stuffed animal by hugging it?
Does your baby get your attention or try to show you something by pulling on your hand or clothes?
Does your child come to you when he needs help, such as with winding up a toy or unscrewing a lid from a jar?
Does your child drink from a cup, putting it down again with little spilling?
Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?
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:
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, or #4 please explain below.
If you answered "YES" to OVERALL questions #5, #6, #7, #8 or #9 please explain below.
MCHAT (Modified Checklist for Autism in Toddlers)
Please answer the below 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.
*
YES
NO
If you point at something across the room, does your child look at it?
Have you ever wondered if your child might be deaf?
Does your child play pretend or make believe?
Does your child like climbing on things?
Does your child make unusual finger movements near his or her eyes?
Does your child point with one finger to ask for something or to get help?
Does your child point with one finger to show you something interesting?
Is your child interested in other children?
Does your child show you things by bringing them to you or holding them up for you to see - not to het help, but just to share?
Does your child respond when you call his or her name?
When you smile at your child, does he or she smile back at you?
Does your child get upset by everyday noises?
Does your child walk?
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?
Does your child try to copy what you do?
If you turn your head to look at something, does your child look around to see what you are looking at?
Does your child try to get you to watch him or her?
Does your child understand when you tell him or her to do something?
If something new happens, does your child look at your face to see how you feel about it?
Does your child like movement activities? (for example, being swung or bounced on your knee)
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