2 MONTH QUESTIONNAIRE
NEWTOWN CENTER PEDIATRICS INTAKE FORM

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 sometimes make throaty or gurgling sounds?
Does your baby make cooing sounds such as "ooo", "gah", and "aah"?
When you speak to your baby, does she make sounds back to you?
Does your baby smile when you talk to him?
Does your baby chuckle softly?
After you have been out of sight, does your baby smile or get excited?
GROSS MOTOR *
YES
SOMTIMES
NOY YET
While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?
When your baby is on her tummy, does she turn her head to the side?
When your baby is on his tummy, does he hold his head up longer than a few seconds?
When your baby is on her back, does she kick her legs?
While your baby is on his back, does he move his head from side to side?
After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?
FINE MOTOR *
YES
SOMETIMES
NOT YET
Is your baby's hand usually tightly closed when he is awake?
Does your baby grasp your finger if you touch the palm of her hand?
When you put a toy in his hand, does your baby hold it in his hand briefly?
Does your baby touch her face with her hands?
Does your baby hold his hands open or partly open when he is awake?
Does your baby grab or scratch at her clothes?
PROBLEM SOLVING *
YES
SOMETIMES
NOT YET
Does your baby look at objects that are 8-10 in. away?
When you move around, does your baby follow you with his eyes?
When you move a toy slowly from side to side in front of your baby's face, does your baby follow the toy with her eyes, sometimes turning her head?
When you move a small toy up and down slowly in front of your baby's face, does your baby follow the toy with his eyes?
When you hold your baby in a sitting position, does she look at a toy that you place on the table or floor in front of her?
When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?
PERSONAL-SOCIAL *
YES
SOMETIMES
NOT YET
Does your baby sometimes try to suck, even when she's not feeding?
Does your baby cry when he is hungry, wet, tired, or wants to be held?
Does your baby smile at you?
When you smile at your baby, does she smile back?
Does your baby watch his hands?
When your baby sees the breast or bottle, does she seem to know she is about to be fed?
OVERALL *
YES
NO
Did your baby pass the newborn hearing test? If no, explain below:
Does your baby move both hands and both legs equally well? If no, explain below:
Does either parent have a family history of childhood deafness, hearing impairment, or vision problems? If yes, explain below:
Has your baby had any medical problems? If yes, explain below:
Do you have concerns about your baby's behavior (eating, sleeping)? If yes, explain below:
Does anything about your baby worry you? If yes, explain below:
If you answered "NO" to OVERALL questions #1 an #2, please explain below.
If you answered "YES" to OVERALL questions #3, #4, #5, #6, please explain below.
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