60 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

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 four-and five-word sentences?

When talking about something that already happened, does your child use words that end in "-ed"?

Does your child use comparison words, such as "heavier," "stronger," or "shorter"?

Does your child answer the following questions appropriately? "What do you do when you are hungry?", "What do you do when you are tired?"

Does your child repeat the following sentences, without any mistakes? "Jane hides her shoes for Maria to find", "Al read the blue book under his bed"

YES

SOMETIMES

NOT YET

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 four-and five-word sentences?

When talking about something that already happened, does your child use words that end in "-ed"?

Does your child use comparison words, such as "heavier," "stronger," or "shorter"?

Does your child answer the following questions appropriately? "What do you do when you are hungry?", "What do you do when you are tired?"

Does your child repeat the following sentences, without any mistakes? "Jane hides her shoes for Maria to find", "Al read the blue book under his bed"

GROSS MOTOR *

YES

SOMTIMES

NOY YET

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

Does your child catch a large ball with both hands?

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?

Does your child walk on his tiptoes for 15 feet?

Does your child hop forward on one foot for a distance of 4-6 feet without putting doe the other foot?

Does your child skip using alternating feet?

YES

SOMTIMES

NOY YET

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

Does your child catch a large ball with both hands?

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?

Does your child walk on his tiptoes for 15 feet?

Does your child hop forward on one foot for a distance of 4-6 feet without putting doe the other foot?

Does your child skip using alternating feet?

FINE MOTOR *

YES

SOMETIMES

NOT YET

Ask your child to trace a horizontal line with a pencil. Does your child trace on the line without going off more than two times?

Ask your child to draw a picture of a person on a blank sheet of paper. If your child draws a person with a head, body, arms, and legs, mark "yes". If you child draws a person with two or fewer parts, mark "not yet."

Draw a line across a piece of paper. Does your child cut the paper in half on the straight line, making the blades go up and down?

Does your child copy shapes, when you draw them (examples: square, triangle, plus sign)

Does your child copy letters, when you write them? (For example: V, H, T, C, A)

Print your child's first name. Can your child copy the letter?

YES

SOMETIMES

NOT YET

Ask your child to trace a horizontal line with a pencil. Does your child trace on the line without going off more than two times?

Draw a line across a piece of paper. Does your child cut the paper in half on the straight line, making the blades go up and down?

Does your child copy shapes, when you draw them (examples: square, triangle, plus sign)

Does your child copy letters, when you write them? (For example: V, H, T, C, A)

Print your child's first name. Can your child copy the letter?

PROBLEM SOLVING *

YES

SOMETIMES

NOT YET

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

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

Does your child count up to 15 without making a mistake?

Does your child finish the following sentences using a word that means the opposite? A. A cow is big, and a mouse is ______ B. Ice is cold , and fire is _______ C. When I throw the ball up, it comes ________

Does your child know the names of numbers?

Does your child name at least four letters in her name?

YES

SOMETIMES

NOT YET

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

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

Does your child count up to 15 without making a mistake?

Does your child know the names of numbers?

Does your child name at least four letters in her name?

PERSONAL-SOCIAL *

YES

SOMETIMES

NOT YET

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

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

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 dress or undress himself without help?

Does your child use the toilet by herself?

Does your child usually take turns and share with other children?

YES

SOMETIMES

NOT YET

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

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

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 dress or undress himself without help?

Does your child use the toilet by herself?

Does your child usually take turns and share with other children?

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: