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9 Month Questionnaire
9 Months 0 Days through 9 Months 30 days
First, you're concern for your child's development shows that you are a great advocate for your child's future.
Early and correct mastery of skills insures that your child will be able to succeed in school and in life.
The questions below are age specific. Be sure your child falls within the age range listed at the top of this form.
You must answer each question. If you are not sure of the answer do your best. It is better to NOT give your child credit if you are not sure if they can perform the task. Try each activity with your child before marking a response. Make the activities fun. Make sure your child is in a good mood, rested and fed.
After you submit the form we will email you the results within 72 hours.
If you have questions please email us at info@Therapy4kids.net or call 501.514.3722
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* Indicates required question
Email
*
Your email
Child's name
*
Your answer
Parent-Guardian Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Where do you live? City and State
*
Your answer
How did you hear about this screening? If preschool, which one?
*
Your answer
Communication
1. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?
*
Yes
Sometimes
Not Yet
2. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?
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Yes
Sometimes
Not Yet
3. Does your baby make two similar sounds like “ba-ba,” “da-da,” or“ga-ga”? (The sounds do not need to mean anything.)
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Yes
Sometimes
Not Yet
4. If you ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,”“clap your hands,” “So Big”)?
*
Yes
Sometimes
Not Yet
5. Does your baby follow one simple command, such as “Come here,”“Give it to me,” or “Put it back,” without your using gestures?
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Yes
Sometimes
Not Yet
6. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)
*
Yes
Sometimes
Not Yet
Gross Motor
1. If you hold both hands just to balance your baby, does she support her own weight while standing?
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Yes
Sometimes
Not Yet
2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?
*
Yes
Sometimes
Not Yet
3. When you stand your baby next to furniture or the crib rail,does she hold on without leaning her chest against the furniture for support?
*
Yes
Sometimes
Not Yet
4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?
*
Yes
Sometimes
Not Yet
5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?
*
Yes
Sometimes
Not Yet
6. Does your baby walk beside furniture while holding on with only one hand?
*
Yes
Sometimes
Not Yet
Fine Motor
1. Does your baby pick up a small toy with only one hand?
*
Yes
Sometimes
Not Yet
2. Does your baby successfully pick up a crumb or Cheerio by using her thumb and all of her fingers in a raking motion? (If she already picks up a crumb or Cheerio, mark “yes” for this item.)
*
Yes
Sometimes
Not Yet
3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)
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Yes
Sometimes
Not Yet
4. After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (The string may be attached to a toy.)
*
Yes
Sometimes
Not Yet
5. Does your baby pick up a crumb or Cheerio with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it.
*
Yes
Sometimes
Not Yet
6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?
*
Yes
Sometimes
Not Yet
Problem Solving
1. Does your baby pass a toy back and forth from one hand to the other?
*
Yes
Sometimes
Not Yet
2. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?
*
Yes
Sometimes
Not Yet
3. When holding a toy in his hand, does your baby bang it against another toy on the table?
*
Yes
Sometimes
Not Yet
4. While holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?
*
Yes
Sometimes
Not Yet
5. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?
*
Yes
Sometimes
Not Yet
6. After watching you hide a small toy under a piece of paper or cloth,does your baby find it? (Be sure the toy is completely hidden.)
*
Yes
Sometimes
Not Yet
Personal - Social
1. While your baby is on her back, does she put her foot in her mouth?
*
Yes
Sometimes
Not Yet
2. Does your baby drink water, juice, or formula from a cup while you hold it?
*
Yes
Sometimes
Not Yet
3. Does your baby feed himself a cracker or a cookie?
*
Yes
Sometimes
Not Yet
4. When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn’t let go of it? (If she already lets go of the toy into your hand, mark “yes” for this item.)
*
Yes
Sometimes
Not Yet
5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?
*
Yes
Sometimes
Not Yet
6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?
*
Yes
Sometimes
Not Yet
Overall
1. Does your baby use both hands and both legs equally well?
*
Yes
No
If No on above question, please explain:
Your answer
2. When you help your baby stand, are his feet flat on the surface most of the time?
*
Yes
No
If No on above question, please explain:
Your answer
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?
*
Yes
No
If Yes on above question, please explain:
Your answer
4. Does either parent have a family history of childhood deafness or hearing impairment?
*
Yes
No
If Yes on above question, please explain:
Your answer
5. Do you have concerns about your baby’s vision?
*
Yes
No
If Yes on above question, please explain:
Your answer
6. Has your baby had any medical problems in the last several months?
*
Yes
No
If Yes on above question, please explain:
Your answer
7. Do you have any concerns about your baby’s behavior?
*
Yes
No
If Yes on above question, please explain:
Your answer
8. Does anything about your baby worry you?
*
Yes
No
If Yes on above question, please explain:
Your answer
What would you like Therapy 4 Kids to provide to the general public?
Examples: Reading/dyslexia help - handwriting class - gymnastics - music lessons - parenting class - art - social skills - anything else
Your answer
Your Phone Number
*
Only used to ensure your receive scoring results. Email can be sent to spam or trash
Your answer
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