48 MONTH QUESTIONNAIRE

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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.

Email *

CHILD'S NAME *

PARENTS NAME COMPLETING FORM *

COMMUNICATION *

YES

SOMETIMES

NOT YET

Does your child name at least three items from a common category? For example, "Tell me the names of some animals."

Does your child answer the following questions? A. "What do you do when you are hungry?" B. What do you do when you are tired?"

Does your child tell you at least two things about common objects? For example, " Tell me about your ball, "does she say something like, "It is round. I throw it/ It's big"?

Does your child use ending of words, such as "-s" "-ed," and "-ing"?

Without you giving help by pointing or repeating, does your child follow three directions that are unrelated to one another? For example, "Clap your hands, walk to the door, and sit down."

Does your child use all of the words in a sentence to make complete sentences, such as "I am going to the park."

YES

SOMETIMES

NOT YET

Does your child name at least three items from a common category? For example, "Tell me the names of some animals."

Does your child answer the following questions? A. "What do you do when you are hungry?" B. What do you do when you are tired?"

Does your child tell you at least two things about common objects? For example, " Tell me about your ball, "does she say something like, "It is round. I throw it/ It's big"?

Does your child use ending of words, such as "-s" "-ed," and "-ing"?

Without you giving help by pointing or repeating, does your child follow three directions that are unrelated to one another? For example, "Clap your hands, walk to the door, and sit down."

Does your child use all of the words in a sentence to make complete sentences, such as "I am going to the park."

GROSS MOTOR *

YES

SOMTIMES

NOY YET

Does your child catch a large ball with both hands?

Does your child climb the rungs of a ladder of a playground slide and slide down without help?

While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away?

Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?

Does your child jump forward a distance of 20 in. from a standing position, starting with his feet together?

Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down?

YES

SOMTIMES

NOY YET

Does your child catch a large ball with both hands?

Does your child climb the rungs of a ladder of a playground slide and slide down without help?

While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away?

Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?

Does your child jump forward a distance of 20 in. from a standing position, starting with his feet together?

Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down?

FINE MOTOR *

YES

SOMETIMES

NOT YET

Does your child put together a five to seven-piece interlocking puzzle?

Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down?

Does your child copy at least three shapes onto a large piece of paper, without tracing?

Does your child unbutton one or more buttons?

Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?

Does your child color mostly within the lines in a coloring book or within the lines of a 2-in. circle that you draw?

YES

SOMETIMES

NOT YET

Does your child put together a five to seven-piece interlocking puzzle?

Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down?

Does your child copy at least three shapes onto a large piece of paper, without tracing?

Does your child unbutton one or more buttons?

Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?

Does your child color mostly within the lines in a coloring book or within the lines of a 2-in. circle that you draw?

PROBLEM SOLVING *

YES

SOMETIMES

NOT YET

When you say, "Say 'five eight three,'" does your child repeat just the three numbers in the same order?

When asked, "Which circle is the smallest?" does your child point to the smallest circle?

Without your giving help by pointing, does your child follow three different directions using the words "under," "between," and "middle"?

When shown objects and asked, "What color is this?" does your child name five different colors?

Does your child dress up and "play-act," pretending to be someone or something else?

If you place five objects in front of your child can he count them by saying the numbers in order?

YES

SOMETIMES

NOT YET

When you say, "Say 'five eight three,'" does your child repeat just the three numbers in the same order?

When asked, "Which circle is the smallest?" does your child point to the smallest circle?

Without your giving help by pointing, does your child follow three different directions using the words "under," "between," and "middle"?

When shown objects and asked, "What color is this?" does your child name five different colors?

Does your child dress up and "play-act," pretending to be someone or something else?

If you place five objects in front of your child can he count them by saying the numbers in order?

PERSONAL-SOCIAL *

YES

SOMETIMES

NOT YET

Does your child serve herself, taking food from one container to another using utensils?

Does your child tell you at least four of the following? A. First Name B. Age C. City she lives in D. Last Name E. Boy or Girl F. Telephone number

Does your child wash his hands using soap and water and dry off with a towel without help?

Does your child tell you the names of two or more playmates?

Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all of her teeth without help?

Does your child dress or undress himself without help?

YES

SOMETIMES

NOT YET

Does your child serve herself, taking food from one container to another using utensils?

Does your child tell you at least four of the following? A. First Name B. Age C. City she lives in D. Last Name E. Boy or Girl F. Telephone number

Does your child wash his hands using soap and water and dry off with a towel without help?

Does your child tell you the names of two or more playmates?

Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all of her teeth without help?

Does your child dress or undress himself without help?

OVERALL *

YES

Do you think your child hears well? If no, explain below:

Do you think your child talks like other children 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: