14 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 baby say three words, such as "Mama," "Dada," and "Baba"?

When your baby wants something, does he tell you by pointing to it?

Does your baby shake his head when he means "no" or "yes"?

Does your baby point to, pat, or try to pick up pictures in a book?

Does your baby say four or more words in addition to "Mama" and "Dada"?

When you ask her to, does your baby go into another room to find a familiar toy or object?

YES

SOMETIMES

NOT YET

Does your baby say three words, such as "Mama," "Dada," and "Baba"?

When your baby wants something, does he tell you by pointing to it?

Does your baby shake his head when he means "no" or "yes"?

Does your baby point to, pat, or try to pick up pictures in a book?

Does your baby say four or more words in addition to "Mama" and "Dada"?

When you ask her to, does your baby go into another room to find a familiar toy or object?

GROSS MOTOR *

YES

SOMTIMES

NOY YET

If you hold both hands just to balance your baby, does he take several steps without tripping or falling?

When you hold one hand just to balance your baby, does she take several steps forward?

Does your baby stand up in the middle of the floor by himself and take several steps forward?

Does your baby climb onto furniture or other large objects, such as large climbing blocks?

Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?

Does your baby move around by walking, rather than by crawling on his hands and knees?

YES

SOMTIMES

NOY YET

If you hold both hands just to balance your baby, does he take several steps without tripping or falling?

When you hold one hand just to balance your baby, does she take several steps forward?

Does your baby stand up in the middle of the floor by himself and take several steps forward?

Does your baby climb onto furniture or other large objects, such as large climbing blocks?

Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?

Does your baby move around by walking, rather than by crawling on his hands and knees?

FINE MOTOR *

YES

SOMETIMES

NOT YET

Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?

Does your baby throw a small ball with a forward arm motion?

Does your baby help turn the pages of a book?

Does your baby stack a small block or toy on top of another one?

Does your baby make a mark on the paper with the tip of a crayon?

Does your baby stack three small blocks or toys on top of each other by herself?

YES

SOMETIMES

NOT YET

Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?

Does your baby throw a small ball with a forward arm motion?

Does your baby help turn the pages of a book?

Does your baby stack a small block or toy on top of another one?

Does your baby make a mark on the paper with the tip of a crayon?

Does your baby stack three small blocks or toys on top of each other by herself?

PROBLEM SOLVING *

YES

SOMETIMES

NOT YET

If you put a small toy into a bowl or box, does your baby copy you by putting in toy, although she may not let go of it? If she lets go, make "yes".

Does your baby drop two small toys, one after the other, into a container like a bowl or box

After your scribble back an forth on paper with a crayon, does your baby copy by scribbling?

Can your baby drop a crumb or Cheerio into a small, clear bottle?

Does your baby drop several small toys, one after another, into a container like a bowl or box?

After you have shown your baby how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?

YES

SOMETIMES

NOT YET

If you put a small toy into a bowl or box, does your baby copy you by putting in toy, although she may not let go of it? If she lets go, make "yes".

Does your baby drop two small toys, one after the other, into a container like a bowl or box

After your scribble back an forth on paper with a crayon, does your baby copy by scribbling?

Can your baby drop a crumb or Cheerio into a small, clear bottle?

Does your baby drop several small toys, one after another, into a container like a bowl or box?

After you have shown your baby how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?

PERSONAL-SOCIAL *

YES

SOMETIMES

NOT YET

When your dress your baby, does she lift her foot for her shoe, sock, or pant leg?

Does your baby roll or throw a ball back to you so that you can return it to him?

Does your baby play with a doll or stuffed animal by hugging it?

Does your baby feed herself with a spoon, even though she may spill some food?

Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?

Does your baby get your attention or try to show you something by pulling on your hand or clothes?

YES

SOMETIMES

NOT YET

When your dress your baby, does she lift her foot for her shoe, sock, or pant leg?

Does your baby roll or throw a ball back to you so that you can return it to him?

Does your baby play with a doll or stuffed animal by hugging it?

Does your baby feed herself with a spoon, even though she may spill some food?

Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?

Does your baby get your attention or try to show you something by pulling on your hand or clothes?

OVERALL *

YES

Does your baby us both hands and both legs equally well? If no, explain below:

Does your baby play with sounds or seem to make words? If no, explain below:

When your baby is standing, are her feet flat on 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 any concerns about your baby's behavior? If yes, explain below?

Does anything about your baby worry you? If yes, explain below: