12 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 make two similar sounds like "ba-ba," "da-da," or "ga-ga"?
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)
Does your baby follow one simple command such as "Come here," Give it to me," or "Put it back," without you using gestures?
Does your baby say three words, such as "Mama," "Dada," and "Baba"?
When you ask, "Where is the ball (hat, shoe, etc.)?" does your baby look at the object? (Make sure the object is present. Mark "yes" if she knows one object.)
When your baby wants something, does he tell you by pointing to it?
GROSS MOTOR *
YES
SOMTIMES
NOY YET
While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?
While holding onto furniture, does your baby lower himself with control?
Does your baby walk beside furniture while holding on with only one hand?
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?
FINE MOTOR *
YES
SOMETIMES
NOT YET
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.)
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.
Does your baby put a small toy down, without dropping it, and then take his hand off the toy?
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?
PROBLEM SOLVING *
YES
SOMETIMES
NOT YET
When holding a toy in his hand, does your baby bang it against another toy on the the table?
Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle?
After watching you hid a small toy under a piece of paper or cloth, does your baby find it?
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".
After you scribble back and forth on paper with a crayon, does your baby copy you by scribbling?
PERSONAL-SOCIAL *
YES
SOMETIMES
NOT YET
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?
When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?
When you hold out your hand and ask for her toy, does your baby let go of it into your hand?
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?
OVERALL *
YES
NO
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:
If you answered "NO" to OVERALL questions #1, #2 or #3, please explain below.
If you answered "YES" to OVERALL questions #4, #5, #6, #7, #8 or #9 please explain below.
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