30 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.

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電子郵件 *

CHILD'S NAME *

PARENTS NAME COMPLETING FORM *

COMMUNICATION *

YES

SOMETIMES

NOT YET

If you point to a picture of something and ask your child "what it is?" do they answer correctly?

Without you giving him clues, can your child carry out at least three of these kind of directions? A. "Put the toy on the table" B. "Close the door" C. "Bring me a towel" D. "Find your coat" E. "Take my hand" F. "Get your book"

Without you showing him, does your child point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts?

Does your child make sentences that are three or four words long?

Without giving your child help by pointing or using gestures, ask him to "put the book on the table" and "put the shoe under the chair." Does your child carry out both of these directions correctly?

When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture? You may ask, "What is the dog doing?"

YES

SOMETIMES

NOT YET

If you point to a picture of something and ask your child "what it is?" do they answer correctly?

Without you showing him, does your child point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts?

Does your child make sentences that are three or four words long?

Without giving your child help by pointing or using gestures, ask him to "put the book on the table" and "put the shoe under the chair." Does your child carry out both of these directions correctly?

When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture? You may ask, "What is the dog doing?"

GROSS MOTOR *

YES

SOMTIMES

NOY YET

Does your child run fairly well, stopping herself without bumping into things or falling?

Does your child walk wither up or down at least two steps by herself? She may hold onto the railing or wall.

Without holding onto anything for support, does your child kick a ball by swinging his leg forward?

Does your child jump with both feet leaving the floor at the same time?

Does your child walk up stairs, using only one foot on each stair?

Does your child stand on one foot for about 1 sec. without holding onto anything?

YES

SOMTIMES

NOY YET

Does your child run fairly well, stopping herself without bumping into things or falling?

Does your child walk wither up or down at least two steps by herself? She may hold onto the railing or wall.

Without holding onto anything for support, does your child kick a ball by swinging his leg forward?

Does your child jump with both feet leaving the floor at the same time?

Does your child walk up stairs, using only one foot on each stair?

Does your child stand on one foot for about 1 sec. without holding onto anything?

FINE MOTOR *

YES

SOMETIMES

NOT YET

Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, or screw lids on and off jars?

After your child watches you draw a line from the top of the paper to the bottom, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction?

Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace?

After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?

Does your child turn pages in a book, one page at a time?

YES

SOMETIMES

NOT YET

Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, or screw lids on and off jars?

Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace?

After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?

Does your child turn pages in a book, one page at a time?

PROBLEM SOLVING *

YES

SOMETIMES

NOT YET

When looking in the mirror, ask, "Where is _______?" (use your child's name) Does your child point to her image in the mirror?

If your child wants something she cannot reach, does she find a chair or box to stand on to reach it?

While your child watches, line up four objects like blocks or cars in a row. Does your child copy you?

When you point to the figure and ask your child, "What is this?" does your child say a word that means a person or something similar?

When you say "Say 'seven three,'" does your child repeat just the two numbers in the same order?

After your child draws a picture, even a simple scribble, does she tell you what she drew?

YES

SOMETIMES

NOT YET

When looking in the mirror, ask, "Where is _______?" (use your child's name) Does your child point to her image in the mirror?

If your child wants something she cannot reach, does she find a chair or box to stand on to reach it?

While your child watches, line up four objects like blocks or cars in a row. Does your child copy you?

When you point to the figure and ask your child, "What is this?" does your child say a word that means a person or something similar?

When you say "Say 'seven three,'" does your child repeat just the two numbers in the same order?

After your child draws a picture, even a simple scribble, does she tell you what she drew?

PERSONAL-SOCIAL *

YES

SOMETIMES

NOT YET

If you do any of the following gestures, does your child copy at least one of them? A. Open and close your mouth B. Blink your eyes C. Pull on your earlobe D. Pat your cheek

Does your child use a spoon to feed himself with little spilling?

Does your child push a wagon, stroller, or other toy on wheels, steering it around objects and backing out of the corners if he cannot turn?

Does your child put on a coat, jacket, or shirt on by himself?

After you put on loose-fitting pants around her feed, does your child pull them completely up to her waist?

When your child is looking in a mirror and you ask, "who is in the mirror?" does he say either "me" or his own name?

YES

SOMETIMES

NOT YET

If you do any of the following gestures, does your child copy at least one of them? A. Open and close your mouth B. Blink your eyes C. Pull on your earlobe D. Pat your cheek

Does your child use a spoon to feed himself with little spilling?

Does your child push a wagon, stroller, or other toy on wheels, steering it around objects and backing out of the corners if he cannot turn?

Does your child put on a coat, jacket, or shirt on by himself?

After you put on loose-fitting pants around her feed, does your child pull them completely up to her waist?

When your child is looking in a mirror and you ask, "who is in the mirror?" does he say either "me" or his own name?

OVERALL *

YES

Do you think your child hears well? If no, explain below:

Do you think your child talks like other toddlers 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: