Ages & Stages Questionnaires ** Well-Child Ages & Stages Screening Questionnaires **For Children 1 Month through 5.5 Years Ages and Stages Questionnaires (ASQ-3) are a series of screening questionnaires for children ages 1 month to 5-1/2 years old. We use the ASQ-3 to make sure your child is developing well and track your child’s progress in important developmental areas such as speech, physical ability, social skills and problem-solving. The ASQ-3 can help us identify your child’s strengths, as well as any areas where he or she may need extra support. The questionnaires may be provided every 2-, 4- or 6-month periods, and are administered as follows: 1. Make your well-child checkup appointment. 2. Print out the screening questionnaire and go through the questions with your child, preferably within a week. 3. Enter your screening results online with this form. This should be completed before your appointment.Are you screening your child, or are you ready to enter the screening results online?I need to print out the questionnaire and screen my childI have screened my child and am ready to enter the information onlineAges & Stages Screening Questionnaire Printouts Please print out the screening questionnaire for your child's age, then go through it with your child. Try to finish this within a week. Once you have finished screening your child, come back and enter the information online. Print Questionnaire for 2 Months (1 month 0 days through 2 months 30 days) Print Questionnaire for 4 Months (3 months 0 days through 4 months 30 days) Print Questionnaire for 6 Months (5 months 0 days through 6 months 30 days) Print Questionnaire for 9 Months (9 months 0 days through 9 months 30 days) Print Questionnaire for 12 Months (11 months 0 days through 12 months 30 days) Print Questionnaire for 16 Months (15 months 0 days through 16 months 30 days) Print Questionnaire for 24 Months (23 months 0 days through 25 months 15 days) Print Questionnaire for 36 Months (34 months 16 days through 38 months 30 days) Print Questionnaire for 48 Months (45 months 0 days through 50 months 30 days) Print Questionnaire for 60 Months (57 months 0 days through 66 months 0 days) Please note that the information you enter into this website is secure and cannot be seen or access by anyone other than the program employees who have invited you to participate in this screening. Today's Date:* Date Format: MM slash DD slash YYYY How old is your child?*-- Please select your child's age --2 Months (1 month 0 days through 2 months 30 days)4 Months (3 months 0 days through 4 months 30 days)6 Months (5 months 0 days through 6 months 30 days)9 Months (9 months 0 days through 9 months 30 days)12 Months (11 months 0 days through 12 months 30 days)16 Months (15 months 0 days through 16 months 30 days)24 Months (23 months 0 days through 25 months 15 days)36 Months (34 months 16 days through 38 months 30 days)48 Months (45 months 0 days through 50 months 30 days)60 Months (57 months 0 days through 66 months 0 days)** 2 Month Questionnaire **Following 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 indicate whether your baby is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your baby before making a response. * Make completing this questionnaire a game that is fun for you and your baby. * Make sure your baby is rested and fed. ** 4 Month Questionnaire **Following 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 indicate whether your baby is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your baby before making a response. * Make completing this questionnaire a game that is fun for you and your baby. * Make sure your baby is rested and fed. ** 6 Month Questionnaire **Following 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 indicate whether your baby is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your baby before making a response. * Make completing this questionnaire a game that is fun for you and your baby. * Make sure your baby is rested and fed. ** 9 Month Questionnaire **Following 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 indicate whether your baby is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your baby before making a response. * Make completing this questionnaire a game that is fun for you and your baby. * Make sure your baby is rested and fed. ** 12 Month Questionnaire **Following 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 indicate whether your baby is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your baby before making a response. * Make completing this questionnaire a game that is fun for you and your baby. * Make sure your baby is rested and fed. ** 16 Month Questionnaire **Following are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please indicate whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your child before making a response. * Make completing this questionnaire a game that is fun for you and your child . * Make sure your child is rested and fed. ** 24 Month Questionnaire **Following are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please indicate whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your child before making a response. * Make completing this questionnaire a game that is fun for you and your child . * Make sure your child is rested and fed. ** 36 Month Questionnaire **Following are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please indicate whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your child before making a response. * Make completing this questionnaire a game that is fun for you and your child . * Make sure your child is rested and fed. ** 48 Month Questionnaire **Following are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please indicate whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your child before making a response. * Make completing this questionnaire a game that is fun for you and your child . * Make sure your child is rested and fed. ** 60 Month Questionnaire **Following are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please indicate whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: * Try each activity with your child before making a response. * Make completing this questionnaire a game that is fun for you and your child . * Make sure your child is rested and fed. BABY'S INFORMATIONBaby's first name:*Middle initial:Baby's last name:*Baby's Date of Birth:* Date Format: MM slash DD slash YYYY If baby was born 3 or more weeks prematurely, # of weeks premature:Baby's gender:*MaleFemaleCHILD'S INFORMATIONChild's first name:*Middle initial:Child's last name:*Child's Date of Birth:* Date Format: MM slash DD slash YYYY Child's gender:*MaleFemalePERSON FILLING OUT QUESTIONNAIREFirst name:*Middle initial:Last name:*Address:*City:*State:*Zip:*Primary phone:*Other phone:Email address:*Relationship to child:*ParentGuardianGrandparent or other relativeFoster parentTeacherChild care providerNames of people assisting in questionnaire completion:PROGRAM INFORMATIONBaby ID #:Age at administration in months and days:Program ID #:If premature, adjusted age in months and days:Program name:PROGRAM INFORMATIONChild ID #:Program ID #:Program name:COMMUNICATION (2 Month)1. Does your baby sometimes make throaty or gurgling sounds?*YesSometimesNot yet2. Does your baby make cooing sounds such as "'ooo," "gah," and "aah"?*YesSometimesNot yet3. When you speak to your baby, does she make sounds back to you?*YesSometimesNot yet4. Does your baby smile when you talk to him?*YesSometimesNot yet5. Does your baby chuckle softty?*YesSometimesNot yet6. After you have been out of sight, does your baby smile or get excited when she sees you?*YesSometimesNot yetGROSS MOTOR (2 Month)1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?*YesSometimesNot yet2. When your baby is on her tummy, does she turn her head to the side?*YesSometimesNot yet3. When your baby is on his tummy, does he hold his head up longer than a few seconds?*YesSometimesNot yet4. When your baby is on her back, does she kick her legs?*YesSometimesNot yet5. While your baby is on his back, does he move his head from side to side?*YesSometimesNot yet6. 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?*YesSometimesNot yetFINE MOTOR (2 Month)1. Is your baby's hand usually tightly closed when he is awake? (If your baby used to do this but no longer does, mark “yes.”)*YesSometimesNot yet2. Does your baby grasp your finger if you touch the palm of her hand?*YesSometimesNot yet3. When you put a toy in his hand, does your baby hold it in his hand briefly?*YesSometimesNot yet4. Does your baby touch her face with her hands?*YesSometimesNot yet5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?*YesSometimesNot yet6. Does your baby grab or scratch at her clothes?*YesSometimesNot yetPROBLEM SOLVING (2 Month)1. Does your baby look at objects that are 8-10 inches away?*YesSometimesNot yet2. When you move around, does your baby follow you with his eyes?*YesSometimesNot yet3. When you move a toy slowly from side to side in front of your baby's face (about 10 inches away), does your baby follow the toy with her eyes, sometimes turning her head?*YesSometimesNot yet4. When you move a small toy up and down slowly in front of your baby’s face (about 10 inches away), does your baby follow the toy with his eyes?*YesSometimesNot yet5. When you hold your baby in a sitting position, does she look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?*YesSometimesNot yet6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?*YesSometimesNot yetPERSONAL-SOCIAL (2 Month)1. Does your baby sometimes try to suck, even when she's not feeding?*YesSometimesNot yet2. Does your baby cry when he is hungry, wet, tired, or wants to be held?*YesSometimesNot yet3. Does your baby smile at you?*YesSometimesNot yet4. When you smile at your baby, does she smile back?*YesSometimesNot yet5. Does you baby watch his hands?*YesSometimesNot yet6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?*YesSometimesNot yetOVERALL (2 Month)1. Did your baby pass the newborn hearing screening test?*YesNoIf no, explain:2. Does your baby move both hands and both legs equally well?*YesNoIf no, explain:3. Does either parent have a family history of childhood deafness, hearing impairment, or vision problems?*YesNoIf yes, explain:4. Has your baby had any medical problems?*YesNoIf yes, explain:5. Do you have concerns about your baby's behavior (for example, eating, sleeping)?*YesNoIf yes, explain:6. Does anything about your baby worry you?*YesNoIf yes, explain:COMMUNICATION (4 Month)1. Does your baby chuckle softly?*YesSometimesNot yet2. After you have been out of sight, does your baby smile or get excited when he sees you?*YesSometimesNot yet3. Does your baby stop crying when she hears a voice other than yours?*YesSometimesNot yet4. Does your baby make high-pitched squeals?*YesSometimesNot yet5. Does your baby laugh?*YesSometimesNot yet6. Does your baby make sounds when looking at toys or people?*YesSometimesNot yetGROSS MOTOR (4 Month)1. While your baby is on his back, does he move his head from side to side?*YesSometimesNot yet2. 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?*YesSometimesNot yet3. When your baby is on his tummy, does he hold his head up so that his chin is about 3 inches from the floor for at least 15 seconds?*YesSometimesNot yet4. When your baby is on her tummy, does she hold her head straight up, looking around? (She can rest on her arms while doing this.)*YesSometimesNot yet5. When you hold him in a sitting position, does your baby hold his head steady?*YesSometimesNot yet6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?*YesSometimesNot yetFINE MOTOR (4 Month)1. Does your baby hold his hands open or partly open (rather than in fists, as they were when he was a newborn)?*YesSometimesNot yet2. When you put a toy in her hand, does your baby wave it about, at least briefly?*YesSometimesNot yet3. Does your baby grab or scratch at his clothes?*YesSometimesNot yet4. When you put a toy in her hand, does your baby hold onto it for about 1 minute while looking at it, waving it about, or trying to chew it?*YesSometimesNot yet5. Does your baby grab or scratch his fingers on a surface in front of him, either while being held in a sitting position or when he is on his tummy?*YesSometimesNot yet6. When you hold your baby in a sitting position, does she reach for a toy on a table close by, even though her hand may not touch it?*YesSometimesNot yetPROBLEM SOLVING (4 Month)1. When you move a toy slowly from side to side in front of your baby's face (about 10 inches away), does your baby follow the toy with his eyes, sometimes turning his head?*YesSometimesNot yet2. When you move a small toy up and down slowly in front of your baby's face (about 10 inches away), does your baby follow the toy with her eyes?*YesSometimesNot yet3. When you hold your baby in a sitting position, does he look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of him?*YesSometimesNot yet4. When you put a toy in her hand, does your baby look at it?*YesSometimesNot yet5. When you put a toy in his hand, does your baby put the toy in his mouth?*YesSometimesNot yet6. When you dangle a toy above your baby while she is lying on her back, does your baby wave his arms toward the toy?*YesSometimesNot yetPERSONAL-SOCIAL (4 Month)1. Does your baby watch his hands?*YesSometimesNot yet2. When your baby has her hands together, does she play with her fingers?*YesSometimesNot yet3. When you baby sees the breast or bottle, does he seem to know he is about to be fed?*YesSometimesNot yet4. Does your baby help hold the bottle with both hands at once, or when nursing, does she hold the breast with her free hand?*YesSometimesNot yet5. Before you smile or talk to your baby, does he smile when he sees you nearby?*YesSometimesNot yet6. When in front of a large mirror, does your baby smile or coo at herself?*YesSometimesNot yetOVERALL (4 Month)1. Does your baby use both hands and both legs equally well?*YesNoIf no, explain:2. When you help your baby stand, are his feet flat on the surface most of the time?*YesNoIf no, explain:3. Do you have concerns that you baby is too quiet or does not make sounds like other babies?*YesNoIf yes, explain:4. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:5. Do you have concerns about your baby's vision?*YesNoIf yes, explain:6. Has your baby had any medical problems in the last several months?*YesNoIf yes, explain:7. Do you have any concerns about your baby's behavior?*YesNoIf yes, explain:8. Does anything about your baby worry you?*YesNoIf yes, explain:COMMUNICATION (6 Month)1. Does your baby make high-pitched squeals?*YesSometimesNot yet2. When playing with sounds, does your baby make grunting, growling, or other deep-toned sounds?*YesSometimesNot yet3. If you call your baby when you are out of sight, does she look in the direction of your voice?*YesSometimesNot yet4. When a loud noise occurs, does your baby turn to see where the sound came from?*YesSometimesNot yet5. Does your baby make sounds like "da," "ga," "ka," and "ba"?*YesSometimesNot yet6. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?*YesSometimesNot yetGROSS MOTOR (6 Month)1. While your baby is on his back, does your baby lift his legs high enough to see his feet?*YesSometimesNot yet2. When your baby is on her tummy, does she straighten both arms and push her whole chest off the bed or floor?*YesSometimesNot yet3. Does your baby roll from his back to his tummy, getting both arms out from under him?*YesSometimesNot yet4. When you put your baby on the floor, does she lean on her hands while sitting? (If she already sits up straight without leaning on her hands, mark "yes" for this item.)*YesSometimesNot yet5. If you hold both hands just to balance your baby does he support his own weight while standing?*YesSometimesNot yet6. Does your baby get into a crawling position by getting up on her hands and knees?*YesSometimesNot yetFINE MOTOR (6 Month)1. Does your baby grab a toy you offer and look at it, wave it about, or chew on it for about 1 minute?*YesSometimesNot yet2. Does your baby reach for or grasp a toy using both hands at once?*YesSometimesNot yet3. Does your baby reach for a crumb or Cheerio and touch it with his finger or hand? (If he already picks up a small object the size of a pea, mark "yes" for this item.)*YesSometimesNot yet4. Does your baby pick up a small toy, holding it in the center of her hand with her fingers around it?*YesSometimesNot yet5. Does your baby try to pick up a crumb or Cheerio by using his thumb and all of his fingers in a raking motion, even if he isn't able to pick it up? (If he already picks up the crumb or Cheerio, mark "yes" for this item.)*YesSometimesNot yet6. Does your baby pick up a small toy with only one hand?*YesSometimesNot yetPROBLEM SOLVING (6 Month)1. When a toy is in front of your baby, does she reach for it with both hands?*YesSometimesNot yet2. When your baby is on his back, does he turn his head to look for a toy when he drops it? (If he already picks it up, mark "yes" for this item.)*YesSometimesNot yet3. When your baby is on her back, does she try to get a toy she has dropped if she can see it?*YesSometimesNot yet4. Does your baby pick up a toy and put it in his mouth?*YesSometimesNot yet5. Does your baby pass a toy back and forth from one hand to the other?*YesSometimesNot yet6. Does your baby play by banging a toy up and down on the floor or table?*YesSometimesNot yetPERSONAL-SOCIAL (6 Month)1. When in front of a large mirror, does your baby smile or coo at herself?*YesSometimesNot yet2. Does your baby act differently toward strangers than he does with you and other familiar people? (Reactions to strangers may include staring, frowning, withdrawing, or crying.)*YesSometimesNot yet3. While lying on her back, does your baby play by grabbing her foot?*YesSometimesNot yet4. When in front of a large mirror, does your baby reach out to pat the mirror?*YesSometimesNot yet5. While your baby is on his back, does he put his foot in his mouth?*YesSometimesNot yet6. Does your baby try to get a toy that is out of reach? (She may roll, pivot on her tummy, or crawl to get it.)*YesSometimesNot yetOVERALL (6 Month)1. Does your baby use both hands and both legs equally well?*YesNoIf no, explain:2. When you help your baby stand, are his feet flat on the surface most of the time?*YesNoIf no, explain:3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*YesNoIf yes, explain:4. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:5. Do you have concerns about your baby's vision?*YesNoIf yes, explain:6. Has your baby had any medical problems in the last several months?*YesNoIf yes, explain:7. Do you have any concerns about your baby's behavior?*YesNoIf yes, explain:6. Does anything about your baby worry you?*YesNoIf yes, explain:COMMUNICATION (9 Month)1. Does your baby make sounds like "da," "ga," "ka," and "ba"?*YesSometimesNot yet2. If you copy the sounds your baby makes does your baby repeat the same sounds back to you?*YesSometimesNot yet3. Does your baby make two similar sounds like "ba-ba," "da-da," or "ga-ga"? (The sounds do not need to mean anything.)*YesSometimesNot yet4. 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," "Peek-a-boo," "clap your hands," "So Big")?*YesSometimesNot yet5. Does your baby follow one simple command, such as "Come here," "Give it to me," or "Put it back," without your using gestures?*YesSometimesNot yet6. 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.)*YesSometimesNot yetGROSS MOTOR (9 Month)1. If you hold both hands just to balance your baby, does she support her own weight while standing?*YesSometimesNot yet2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?*YesSometimesNot yet3. 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?*YesSometimesNot yet4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?*YesSometimesNot yet5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?*YesSometimesNot yet6. Does your baby walk beside furniture while holding on with only one hand?*YesSometimesNot yetFINE MOTOR (9 Month)1. Does your baby pick up a small toy with only one hand?*YesSometimesNot yet2. 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.)*YesSometimesNot yet3. 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.)*YesSometimesNot yet4. 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.)*YesSometimesNot yet5. 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.*YesSometimesNot yet6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?*YesSometimesNot yetPROBLEM SOLVING (9 Month)1. Does your baby pass a toy back and forth from one hand to the other?*YesSometimesNot yet2. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?*YesSometimesNot yet3. When holding a toy in his hand, does your baby bang it against another toy on the table?*YesSometimesNot yet4. While holding a small toy in each hand, does your baby clap the toys together (like "Pat-a-cake")?*YesSometimesNot yet5. 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)?*YesSometimesNot yet6. 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.)*YesSometimesNot yetPERSONAL-SOCIAL (9 Month)1. Wile your baby is on her back, does she put her foot in her mouth?*YesSometimesNot yet2. Does your baby drink water, juice or formula from a cup while you hold it?*YesSometimesNot yet3. Does your baby feed himself a cracker or a cookie?*YesSometimesNot yet4. 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.)*YesSometimesNot yet5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?*YesSometimesNot yet6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?*YesSometimesNot yetOVERALL (9 Month)1. Does your baby use both hands and both legs equally well?*YesNoIf no, explain:2. When you help your baby stand, are his feet flat on the surface most of the time?*YesNoIf no, explain:3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*YesNoIf yes, explain:4. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:5. Do you have concerns about your baby's vision?*YesNoIf yes, explain:6. Has your baby had any medical problems in the last several months?*YesNoIf yes, explain:7. Do you have any concerns about your baby's behavior?*YesNoIf yes, explain:8. Does anything about your baby worry you?*YesNoIf yes, explain:COMMUNICATION (12 Month)1. Does your baby make two similar sounds like "ba-ba," "da-da," or "ga-ga"? (The sounds do not need to mean anything.)*YesSometimesNot yet2. 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," "Peek-a-boo," "clap your hands," "So Big")?*YesSometimesNot yet3. Does your baby follow one simple command, such as "Come here," "Give it to me," or "Put it back," without your using gestures?*YesSometimesNot yet4. 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.)*YesSometimesNot yet5. 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.)*YesSometimesNot yet6. When your baby wants something, does he tell you by pointing to it?*YesSometimesNot yetGROSS MOTOR (12 Month)1. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?*YesSometimesNot yet2. While holding onto furniture, does your baby lower herself with control (without falling or flopping down)?*YesSometimesNot yet3. Does your baby walk beside furniture while holding on with only one hand?*YesSometimesNot yet4. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark "yes" for this item.)*YesSometimesNot yet5. When you hold one hand just to balance your baby, does she take several steps forward? (If your baby already walks alone, mark "yes" for this item.)*YesSometimesNot yet6. Does your baby stand up in the middle of the floor by himself and take several steps forward?*YesSometimesNot yetFINE MOTOR (12 Month)1. After one or two tries, does your baby pick up a piece of string with his first finger and thumb? (The string may be attached to a toy.)*YesSometimesNot yet2. Does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger? She may rest her arm or hand on the table while doing it.*YesSometimesNot yet3. Does your baby put a small toy down, without dropping it, and then take his hand off the toy?*YesSometimesNot yet4. 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?*YesSometimesNot yet5. Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark "not yet" for this item.)*YesSometimesNot yet6. Does your baby help turn the pages of a book? (You may lift a page for him to grasp.)*YesSometimesNot yetPROBLEM SOLVING (12 Month)1. When holding a small toy in each hand, does your baby clap the toys together (like "Pat-a-cake")?*YesSometimesNot yet2. 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)?*YesSometimesNot yet3. 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.)*YesSometimesNot yet4. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although she may not let go of it? (If she already lets go of the toy into a bowl or box, mark "yes" for this item.)*YesSometimesNot yet5. Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show him how to do it.)*YesSometimesNot yet6. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If she already scribbles on her own, mark "yes" for this item.)*YesSometimesNot yetPERSONAL-SOCIAL (12 Month)1. When you hold out your hand and ask for his toy, does your baby offer it to you even if he doesn't let go of it? (If he already lets go of the toy into your hand, mark "yes" for this item.)*YesSometimesNot yet2. When you dress your baby, does she push her arm through a sleeve once her arm is started in the hole of the sleeve?*YesSometimesNot yet3. When you hold out your hand and ask for his toy, does your baby let go of it into your hand?*YesSometimesNot yet4. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?*YesSometimesNot yet5. Does your baby roll or throw a ball back to you so that you can return it to him?*YesSometimesNot yet6. Does your baby play with a doll or stuffed animal by hugging it?*YesSometimesNot yetOVERALL (12 Month)1. Does your baby use both hands and both legs equally well?*YesNoIf no, explain:2. Does your baby play with sounds or seem to make words?*YesNoIf no, explain:3. When your baby is standing, are her feet flat on the surface most of the time?*YesNoIf no, explain:4. Do you have concerns that your baby is too quiet or does not make sounds like other babies do?*YesNoIf yes, explain:5. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:6. Do you have concerns about your baby's vision?*YesNoIf yes, explain:7. Has your baby had any medical problems in the last several months?*YesNoIf yes, explain:8. Do you have any concerns about your baby's behavior?*YesNoIf yes, explain:9. Does anything about your baby worry you?*YesNoIf yes, explain:COMMUNICATION (16 Month)1. Does your child point to, pat, or try to pick up pictures in a book?*YesSometimesNot yet2. Does your child say four or more words in addition to "Mama" and "Dada"?*YesSometimesNot yet3. When your child wants something, does she tell you by pointing to it?*YesSometimesNot yet4. When you ask your child to, does he go into another room to find a familiar toy or object? (You might ask, "Where is your ball?" or say, "Bring me your coat," or "Go get your blanket.")*YesSometimesNot yet5. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as "Mama eat," "Daddy play," "Go home," or "What's this?" does your child say both words back to you? (Mark "yes" even if her words are difficult to understand.)*YesSometimesNot yet5. Does your child say eight or more words in addition to "Mama" and "Dada"?*YesSometimesNot yetGROSS MOTOR (16 Month)1. Does your child stand up in the middle of the floor by himself and take several steps forward?*YesSometimesNot yet2. Does your child climb onto furniture or other large objects, such as large climbing blocks?*YesSometimesNot yet3. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?*YesSometimesNot yet4. Does your child move around by walking, rather than crawling on her hands and knees?*YesSometimesNot yet5. Does your child walk well and seldom fall?*YesSometimesNot yet6. Does your child climb on an object such as a chair to reach something he wants (for example, to get a toy on a counter or to "help" you in the kitchen)?*YesSometimesNot yetFINE MOTOR (16 Month)1. Does your child help turn the pages of a book? (You may lift a page for her to grasp.)*YesSometimesNot yet2. Does your child throw a small ball with a forward arm motion? (If he simply drops the ball, mark "not yet" for this item.)*YesSometimesNot yet3. Does your child stack a small block or toy on top of another one? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)*YesSometimesNot yet4. Does your child stack three small blocks or toys on top of each other by herself?*YesSometimesNot yet5. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?*YesSometimesNot yet6. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)*YesSometimesNot yetPROBLEM SOLVING (16 Month)1. After you scribble back and forth on paper with a crayon (or pencil or pen), does your child copy you by scribbling? (If she already scribbles on her own, mark "yes" for this item.)*YesSometimesNot yet2. Can your child drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?*YesSometimesNot yet3. Does your child drop several small toys, one after another, into a container like a bowl or box? (You may show him how to do it.)*YesSometimesNot yet4. After you have shown your child how, does she try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?*YesSometimesNot yet5. Without your showing him how, does your child scribble back and forth when you give him a crayon (or pencil or pen)?*YesSometimesNot yet6. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump it out? (You may show her how.)*YesSometimesNot yetPERSONAL-SOCIAL (16 Month)1. Does your child feed himself with a spoon, even thought he may spill some food?*YesSometimesNot yet2. Does your child help undress herself by taking off clothes like socks, hat, shoes, or mittens?*YesSometimesNot yet3. Does your child play with a doll or stuffed animal by hugging it?*YesSometimesNot yet4. While looking at himself in the mirror, does your child offer a toy to his own image?*YesSometimesNot yet5. Does you child get your attention or try to show you something by pulling on your hand or clothes?*YesSometimesNot yet6. Does your child come to you when she needs help, such as a with winding up toy or unscrewing a lid from a jar?*YesSometimesNot yetOVERALL (16 Month)1. Do you think your child hears well?*YesNoIf no, explain:2. Do you think your child talks like other toddlers his age?*YesNoIf no, explain:3. Can you understand most of what your child says?*YesNoIf no, explain:4. Do you think your child walks, runs, and climbs like other toddlers her age?*YesNoIf no, explain:5. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:6. Do you have concerns about your child's vision?*YesNoIf yes, explain:7. Has your child had any medical problems in the last several months?*YesNoIf yes, explain:8. Do you have any concerns about your child's behavior?*YesNoIf yes, explain:9. Does anything about your child worry you?*YesNoIf yes, explain:COMMUNICATION (24 Month)1. Without your showing him, does your child point to the correct picture when you say, "Show me the kitty,” or ask, "Where is the dog?" (She needs to identify only one picture correctly.)*YesSometimesNot yet2. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as "Mama eat,“ "Daddy play,· "Go home,“ or "What's this?" does your child say both words back to you? (Mark "yes" even if her words are difficult to understand.)*YesSometimesNot yet3. Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?*YesSometimesNot yet 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.” 4. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, "What is this?" does your child correctly name at least one picture?*YesSometimesNot yet5. Does your child say two or three words that represent different ideas together, such as "See dog," "Mommy come home," or "Kitty gone"? (Don't count word combinations that express one idea, such as "bye-bye," "all gone," "all right," and "What's that?")*YesSometimesNot yetPlease give an example of your child's word combinations:*6. Does your child correctly use at least two words like "me," "I," "mine ," and "you"?*YesSometimesNot yetGROSS MOTOR (24 Month)1. Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)*YesSometimesNot yet2. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (If your child already kicks a ball, mark "yes” for this item.)*YesSometimesNot yet3. Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wall.*YesSometimesNot yet4. Does your child run fairly well, stopping herself without bumping into things or falling?*YesSometimesNot yet5. Does your child jump with both feet leaving the floor at the same time?*YesSometimesNot yet6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?*YesSometimesNot yetFINE MOTOR (24 Month)1. Does your child get a spoon into his mouth right side up so that the food usually doesn't spill?*YesSometimesNot yet2. Does your child turn the pages of a book by herself? (She may turn more than one page at a time.)*YesSometimesNot yet3. Does your child use a turning motion with his hand while trying to turn doorknobs, windup toys, twist tops, or screw lids on and off jars?*YesSometimesNot yet4. Does your child flip switches off and on?*YesSometimesNot yet5. Does your child stack seven small blocks or toys on top of each other by herself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)*YesSometimesNot yet6. Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace?*YesSometimesNot yetPROBLEM SOLVING (24 Month)1. After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark "not yet" if your child scribbles back and forth .)*YesSometimesNot yet2. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump out the crumb or Cheerio? (Do not show him how.) (You can use a soda-pop bottle or baby bottle.)*YesSometimesNot yet3. Does your child pretend objects are something else? For example, does your child hold a cup to her ear, pretending it is a telephone? Does she put a box on her head, pretending it is a hat? Does she use a block or small toy to stir food?*YesSometimesNot yet4. Does your child put things away where they belong? For example, does he know his toys belong on the toy shelf, his blanket goes on his bed, and dishes go in the kitchen?*YesSometimesNot yet5. If your child wants something she cannot reach, does she find a chair or box to stand on to reach it (for example, to get a toy on a counter or to "help" you in the kitchen)?*YesSometimesNot yet6. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.)*YesSometimesNot yetPERSONAL-SOCIAL (24 Month)1. Does your child drink from a cup or glass, putting it down again with little spilling?*YesSometimesNot yet2. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?*YesSometimesNot yet3. Does your child eat with a fork?*YesSometimesNot yet4. When playing with either a stuffed animal or a doll, does your child pretend to rock it, feed it, change its diapers, put it to bed, and so forth?*YesSometimesNot yet5. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if he cannot turn?*YesSometimesNot yet6. Does your child call herself "I" or "me" more often than her own name? For example, "I do it," more often than "Juanita do it."*YesSometimesNot yetOVERALL (24 Month)1. Do you think your child hears well?*YesNoIf no, explain:2. Do you think your child talks like other toddlers her age?*YesNoIf no, explain:3. Can you understand most of what your child says?*YesNoIf no, explain:4. Do you think your child walks, runs, and climbs like other toddlers his age?*YesNoIf no, explain:5. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:6. Do you have any concerns about your child's vision?*YesNoIf yes, explain:7. Has your child had any medical problems in the last several months?*YesNoIf yes, explain:8. Do you have any concerns about your child's behavior?*YesNoIf yes, explain:9. Does anything about your child worry you?*YesNoIf yes, explain:COMMUNICATION (36 Month)1. When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark "sometimes" if she correctly points to at least three different body parts.)*YesSometimesNot yet2. Does your child make sentences that are three or four words long?*YesSometimesNot yetPlease give an example:*3. 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?*YesSometimesNot yet4. When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, "barking," "running," "eating," or "crying")? You may ask, "What is the dog (or boy) doing?"*YesSometimesNot yet5. Show your child how a zipper on a coat moves up and down, and say, "See, this goes up and down." Put the zipper to the middle and ask your child to move the zipper down. Return the zipper to the middle and ask your child to move the zipper up. Do this several times, placing the zipper in the middle before asking your child to move it up or down. Does your child consistently move the zipper up when you say "up" and down when you say "down"?*YesSometimesNot yet6. When you ask, "What is your name?" does your child say both her first and last names?*YesSometimesNot yetGROSS MOTOR (36 Month)1. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?*YesSometimesNot yet2. Does your child jump with both feet leaving the floor at the same time?*YesSometimesNot yet3. Does your child walk upstairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)*YesSometimesNot yet4. Does your child stand on one foot for about 1 second without holding onto anything?*YesSometimesNot yet5. While standing, does your child throw a ball overhand by raising his arm to shoulder height and throwing the ball forward? (Dropping the ball or throwing the ball underhand should be scored as "not yet.")*YesSometimesNot yet6. Does your child jump forward at least 6 inches with both feet leaving the ground at the same time?*YesSometimesNot yetFINE MOTOR (36 Month)1. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask her 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?*YesSometimesNot yet2. Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace?*YesSometimesNot yet3. 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?*YesSometimesNot yet4. After your child watches you draw a line from one side of the paper to the other side, ask her 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 horizontal direction?*YesSometimesNot yet5. Does your child try to cut paper with child-safe scissors? He does not need to cut the paper but must get the blades to open and close while holding the paper with the other hand. (You may show your child how to use scissors. Carefully watch your child's use of scissors for safety reasons.)*YesSometimesNot yet6. When drawing, does your child hold a pencil, crayon, or pen between her fingers and thumb like an adult does?*YesSometimesNot yetPROBLEM SOLVING (36 Month)1. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.)*YesSometimesNot yet2. If your child wants something he cannot reach, does he find a chair or box to stand on to reach it (for example, to get a toy on a counter or to "help" you in the kitchen)?*YesSometimesNot yet3. 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? (Mark "yes" for responses like "snowman," "boy," "man," "girl," "Daddy," "spaceman," and "monkey.")*YesSometimesNot yetPlease write your child's response here:*4. When you say, "Say 'seven three,'" does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, "Say 'eight two.'" (Your child must repeat just one series of two numbers for you to answer "yes" to this question.)*YesSometimesNot yet5. Show your child how to make a bridge with blocks, boxes, or cans. Does your child copy you by making one like it?*YesSometimesNot yet6. When you say, "Say 'five eight three,"' does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, "Say 'six nine two."' (Your child must repeat just one series of three numbers for you to answer "yes" to this question.)*YesSometimesNot yetPERSONAL-SOCIAL (36 Month)1. Does your child use a spoon to feed herself with little spilling?*YesSometimesNot yet2. Does your child push a little wagon, stroller, or toy on wheels, steering it around objects and backing out of corners if he cannot turn?*YesSometimesNot yet3. When your child is looking in a mirror and you ask, "Who is in the mirror?" does she say either "me" or her own name?*YesSometimesNot yet4. Does your child put on a coat, jacket, or shirt by himself?*YesSometimesNot yet5. Using these exact words, ask your child, "Are you a girl or a boy?" Does your child answer correctly?*YesSometimesNot yet6. Does your child take turns by waiting while another child or adult takes a turn?*YesSometimesNot yetOVERALL (36 Month)1. Do you think your child hears well?*YesNoIf no, explain:2. Do you think your child talks like other children her age?*YesNoIf no, explain:3. Can you understand most of what your child says?*YesNoIf no, explain:4. Can other people understand most of what your child says?*YesNoIf no, explain:5. Do you think your child walks, runs, and climbs like other children his age?*YesNoIf no, explain:6. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:7. Do you have any concerns about your child's vision?*YesNoIf yes, explain:8. Has your child had any medical problems in the last several months?*YesNoIf yes, explain:9. Do you have any concerns about your child's behavior?*YesNoIf yes, explain:10 . Does anything about your child worry you?*YesNoIf yes, explain:COMMUNICATION (48 Month)1. Does your child name at least three items from a common category? For example, if you say to your child, "Tell me some things that you can eat,” does your child answer with something like "cookies, eggs, and cereal"? Or if you say. "Tell me the names of some animals, does your child answer with something like "cow, dog, and elephant"?*YesSometimesNot yet2. Does your child answer the following questions? (Mark "sometimes” if your child answers only one question.) Please write your child's response:*YesSometimesNot yet"What do you do when you are hungry?" (Acceptable answers include "get food," "eat," "ask for something to eat," and "have a snack.") Please write your child's response:*"What do you do when you are tired?" (Acceptable answers include "take a nap,” “rest,” “go to sleep,” “go to bed,” "lie down,” and "sit down.")*3. Does your child tell you at least two things about common objects? For example, if you say to your child, "Tell me about your ball,” does she say something like, "It's round. I throw it. It's big"?*YesSometimesNot yet4. Does your child use endings of words, such as “-s,” “-ed,” and “-ing”? For example, does your child say things like, "I see two cats,” "I am playing," or "I kicked the ball"?*YesSometimesNot yet5. Without your giving help by pointing or repeating, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down," or "Give me the pen, open the book, and stand up."*YesSometimesNot yet6. Does your child use all of the words in a sentence (for example, "a," "the," "am," "is," and "are") to make complete sentences, such as "I am going to the park," or "Is there a toy to play with?" or "Are you coming, too?"*YesSometimesNot yetGROSS MOTOR (48 Month)1. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)*YesSometimesNot yet2. Does your child climb the rungs of a ladder of a playground slide and slide down without help?*YesSometimesNot yet3. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as "not yet.")*YesSometimesNot yet4. Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?*YesSometimesNot yet5. Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together?*YesSometimesNot yet6. 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? (You may give your child two or three tries before you mark the answer.)*YesSometimesNot yetFINE MOTOR (48 Month)1. Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)*YesSometimesNot yet2. Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child's use of scissors for safety reasons.)*YesSometimesNot yet3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, without tracing? (Your child's drawings should look similar to the design of the shapes below, but they may be different in size.)*YesSometimesNot yet4. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll's clothing.)*YesSometimesNot yet5. Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?*YesSometimesNot yet6. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.)*YesSometimesNot yetPROBLEM SOLVING (48 Month)1. When you say, "Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, "Say 'six nine two.’” (Your child must repeat just one series of three numbers to answer "yes" to this question.)*YesSometimesNot yet2. When asked, "Which circle is the smallest?" does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)*YesSometimesNot yet3. Without your giving help by pointing, does your child follow three different directions using the words "under," "between," and "middle"? For example, ask your child to put the shoe "under the couch." Then ask her to put the ball "between the chairs" and the book "in the middle of the table."*YesSometimesNot yet4. When shown objects and asked, "What color is this?" does your child name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark "yes" only if your child answers the question correctly using five colors.)*YesSometimesNot yet5. Does your child dress up and "play-act," pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.*YesSometimesNot yet6. If you place five objects in front of your child, can he count them by saying, "one, two, three, four, five," in order? (Ask this question without providing help by pointing, gesturing, or naming.)*YesSometimesNot yetPERSONAL-SOCIAL (48 Month)1. Does your child serve herself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?*YesSometimesNot yet2. Does your child tell you at least four of the following?*YesSometimesNot yetPlease mark the items your child knows. First name Age City she lives in Last name Boy or girl Telephone number 3. Does your child wash his hands using soap and water and dry off with a towel without help?*YesSometimesNot yet4. Does your child tell you the names of two or more playmates, not including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)*YesSometimesNot yet5. Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all of her teeth without help? (You may still need to check and rebrush your child's teeth.)*YesSometimesNot yet6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?*YesSometimesNot yetOVERALL (48 Month)1. Do you think your child hears well?*YesNoIf no, explain:2. Do you think your child talks like other children her age?*YesNoIf no, explain:3. Can you understand most of what your child says?*YesNoIf no, explain:4. Can other people understand most of what your child says?*YesNoIf no, explain:5. Do you think your child walks, runs, and climbs like other children his age?*YesNoIf no, explain:6. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:7. Do you have any concerns about your child's vision?*YesNoIf yes, explain:8. Has your child had any medical problems in the last several months?*YesNoIf yes, explain:9. Do you have any concerns about your child's behavior?*YesNoIf yes, explain:10. Does anything about your child worry you?*YesNoIf yes, explain:COMMUNICATION (60 Month)1. Without your giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down," or "Give me the pen, open the book, and stand up."*YesSometimesNot yet2. Does your child use four- and five-word sentences? For example, does your child say, "I want the car"?*YesSometimesNot yetPlease write an example:*3. When talking about something that already happened, does your child use words that end in "-ed," such as "walked," "jumped," or "played"? Ask your child questions, such as "How did you get to the store?" ("We walked.") "What did you do at your friend's house?" ('We played.")*YesSometimesNot yetPlease write an example:*4. Does your child use comparison words, such as "heavier," "stronger," or "shorter"? Ask your child questions, such as "A car is big, but a bus is __ " (bigger); "A cat is heavy, but a man is __ " (heavier); "A TV is small, but a book is __ " (smaller).*YesSometimesNot yetPlease write an example:*5. Does your child answer the following questions? (Mark "sometimes" if your child answers only one question.)*YesSometimesNot yet"What do you do when you are hungry?" (Acceptable answers include "get food," "eat," "ask for something to eat," and "have a snack.") Please write your child's response:*"What do you do when you are tired?" (Acceptable answers include: "take a nap," ''rest," ''go to sleep," ''go to bed," ''lie down," and ''sit down.") Please write your child's response:*6. Does your child repeat the sentences shown below back to you, without any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark "yes" if your child repeats both sentences without mistakes or "sometimes" if your child repeats one sentence without mistakes.) Jane hides her shoes for Maria to find. AI read the blue book under his bed.*YesSometimesNot yetGROSS MOTOR (60 Month)1. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as "not yet.")*YesSometimesNot yet2. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)*YesSometimesNot yet3. 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? (You may give your child two or three tries before you mark the answer.)*YesSometimesNot yet4. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)*YesSometimesNot yet5. Does your child hop forward on one foot for a distance of 4-6 feet without putting down the other foot? (You may give her two tries on each foot. Mark "sometimes" if she can hop on one foot only.)*YesSometimesNot yet6. Does your child skip using alternating feet? (You may show him how to do this.)*YesSometimesNot yetFINE MOTOR (60 Month)1. Ask your child to trace on the line below with a pencil. Does your child trace on the line without going off the line more than two times? (Mark "sometimes" if your child goes off the line three times.)*YesSometimesNot yet2. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, "Draw a picture of a girl or a boy." If your child draws a person with head, body, arms, and legs, mark "yes." If your child draws a person with only three parts (head, body, arms, or legs), mark "sometimes." If your child draws a person with two or fewer parts (head, body, arms, or legs), mark "not yet." Be sure to include the sheet of paper with your child's drawing with this questionnaire.*YesSometimesNot yet3. Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child's use of scissors for safety reasons.)*YesSometimesNot yet4. Using the shapes below to look at, does your child copy the shapes in the space below without tracing? (Your child's drawings should look similar to the design of the shapes below, but they may be different in size. Mark "yes” if she copies all three shapes; mark "sometimes" if your child copies two shapes.)*YesSometimesNot yet5. Using the letters below to look at, does your child copy the letters without tracing? Cover up all of the letters except the letter being copied. (Mark "yes" if your child copies four of the letters and you can read them. Mark "sometimes" if your child copies two or three letters and you can read them.)*YesSometimesNot yet6. Print your child's first name. Can your child copy the letters? The letters may be large, backward, or reversed. (Mark "sometimes" if your child copies about half of the letters.)*YesSometimesNot yetPROBLEM SOLVING (60 Month)1. When asked, "Which circle is smallest?" does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)*YesSometimesNot yet2. When shown objects and asked, "What color is this?" does your child name five different colors like red, blue, yellow, orange, black, white, or pink? (Mark "yes" only if your child answers the question correctly using five colors.)*YesSometimesNot yet3. Does your child count up to 15 without making mistakes? If so, mark "yes." If your child counts to 12 without making mistakes, mark "sometimes."*YesSometimesNot yet4. Does your child finish the following sentences using a word that means the opposite of the word that is italicized? For example: "A rock is hard, and a pillow is soft." (Mark "yes" if he finishes three of four sentences correctly. Mark "sometimes" if he finishes two of four sentences correctly.) Please write your child's responses below:*YesSometimesNot yetA cow is big, and a mouse is*Ice is cold, and fire is*We see stars at night, and we see the sun during the*When I throw the ball up, it comes*5. Does your child know the names of numbers? (Mark "yes" if she identifies the three numbers below. Mark "sometimes" if she identifies two numbers.)*YesSometimesNot yet6. Does your child name at least four letters in her name? Point to the letters and ask, "What letter is this?" (Point to the letters out of order.)*YesSometimesNot yetPERSONAL-SOCIAL (60 Month)1. Can your child serve himself, taking food from one container to another, using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?*YesSometimesNot yet2. Does your child wash her hands and face using soap and water and dry off with a towel without help?*YesSometimesNot yet3. Does your child tell you at least four of the following?*YesSometimesNot yetPlease mark the items your child knows.* First name Age City he lives in Last name Boy or girl Telephone number 4. Does your child dress and undress himself, including buttoning medium-size buttons and zipping front zippers?*YesSometimesNot yet5. Does your child use the toilet by herself? (She goes to the bathroom, sits on the toilet, wipes, and flushes.) Mark "yes" even if she does this after you remind her.*YesSometimesNot yet6. Does your child usually take turns and share with other children?*YesSometimesNot yetOVERALL (60 Month)1. Do you think your child hears well?*YesNoIf no, explain:2. Do you think your child talks like other children her age?*YesNoIf no, explain:3. Can you understand most of what your child says?*YesNoIf no, explain:4. Can other people understand most of what your child says?*YesNoIf no, explain:5. Do you think your child walks, runs, and climbs like other children his age?*YesNoIf no, explain:6. Does either parent have a family history of childhood deafness or hearing impairment?*YesNoIf yes, explain:7. Do you have any concerns about your child's vision?*YesNoIf yes, explain:8. Has your child had any medical problems in the last several months?*YesNoIf yes, explain:9. Do you have any concerns about your child's behavior?*YesNoIf yes, explain:10. Does anything about your child worry you?*YesNoIf yes, explain:Location and HFM ProviderPlease select your HFM location:*ClaytonFour OaksRiverwoodSmithfieldWhich Clayton Provider do you see?*Dr. WilliamsDr. HarrisDr. KahnDr. McGillDr. SelakDr. NorrisMegan Wester, PABrittany McCall, FNP-CWhich Four Oaks Provider do you see?*Dr. WatsonCourtney Powell, PA-CWhich Riverwood Provider do you see?*Dr. HebdaJessica Heath, MPAS, PA-CWhich Smithfield Provider do you see?*Dr. PittardDr. LivermanDr. DavisDr. RyanJenah Manzano, PA-CNameThis field is for validation purposes and should be left unchanged.
