9 Month Questionnaire

 
On the following pages are questions about activities children 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 check the box that tells whether your child is doing the activity regularly, sometimes, or not yet.
 

Important points to remember:



 
Child's Full Name: 
Child's Gender: Male Female
Child's Date of Birth: 
 
Child's corrected date of birth (if child is premature, add weeks of prematurity to the child's date of birth): 
 
Today's Date: 
 
Person filling out this questionnaire: 
 
What is your relationship to the child?: 
 
Home phone number: 

Other phone number:
Your mailing address: 
 
City: 
State: 
Zip: 
 
Email Address:
Administering program or provider:
 
List of people assisting in the questionnaire completion:
 
 

Communication    

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?  
2. Does your baby make two similar sounds like "ba-ba", "da-da", or "ga-ga"? (The sounds do not need to mean anything.)  
3. If you ask your baby to, does he play at least one nursery game even if you don't show her the activity yourself (such as "bye-bye", "Peeka-boo", "clap your hands", "So Big")?  
4. Does your baby follow one simple command, such as "Come here", "Give it to me", or "Put it back", without your using gestures?  
5. Does your baby make sounds like "da", "ga", "ka", and "ba"?  
6. 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.)  
        Communication Total: 
 

Gross Motor

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?
 
2. When you stand your baby next to furniture or the crib rail, does he/she hold on without leaning his/her chest against the furniture for support?
 
3. While holding onto furniture, does your baby lower himself/herself with control (without falling or flopping down)?  
4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?
 
5. If you hold both hands just to balance him/her, does your baby support his/her own weight while standing?
 
6. Does your baby walk beside furniture while holding on with only one hand?  
        Gross Motor Total:

 
 

   


Fine Motor

Be sure to try each activity with your child.


 
  YES SOMETIMES NOT YET  
1. Does your baby pick up a small toy with only one hand?
 
2. Does your baby pick up a small toy with the tips of their thumb and fingers? (You should see a space between the toy and his palm.)
 
3. After one or two ties, does your baby pick up a piece of string with his/her first finger and thumb? (The string may be attached to a toy)
 
4. Does your baby pick up a crumb or Cheerios with the tips of his/her thumb and a finger? They may rest their arm or hand on the table while doing it.
 
5. Does your baby successfully pick up a crumb or Cheerio by using his/her thumb and all his/her fingers in a raking motion, even if they isn't able to pick it up? (If he/she already picks up the crumb or Cheerio, then check "yes" for this item)
 
6. Does your baby put a small toy down, without dropping it, and then take their hand off the toy?  
        Fine Motor Total:
 

Problem Solving

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. Does your baby pass a toy back and forth from one hand to the other?
 
2. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?
 
3. When holding a toy in his hand, does your baby bang it against another toy on the table?
 
4. While holding a small toy in each hand, does your baby clap the toys together (like "Pat-a-cake")?  
5. 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 a baby bottle)?  
6. 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)  
        Problem Solving Total:
 

 

Personal-Social

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. While your baby is on their back, does he/she put her foot in her mouth? 
 
2. Does your baby drink water, juice, or formula from a cup while you hold it?   
3. Does your baby feed himself/herself a cracker or cookie?  
4. When you hold out your hand and ask for a toy, does your baby offer it to you even if they doesn't let go of it? (If she already lets go of the toy into our hand, mark "yes" for this item)  
5. When you dress your baby, do they push their arm through a sleeve once their arm is started in the hole of the sleeve?  
6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?  
        Personal-social Total: 
 

Overall

Parents and providers may use the back of this sheet for additional comments.
1. Does your baby use both hands and both legs equally well? YES NO If no, explain:
2. When you help your baby stand, are his feet flat on the surface most of the time? YES NO If no, explain:
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies? YES NO If yes, explain:
4. Does either parent have a family history of childhood deafness or hearing impairment? YES NO If yes, explain:
5. Do you have concerns about your child's vision? YES NO If yes, explain:
6. Has your child had any medical problems in the last several months? YES NO If yes, explain:
7. Do you have any concerns about your baby's behavior? YES NO If yes, explain:
8. Does anything about your baby worry you? YES NO If yes, explain: