12 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 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")?  
2. Does your baby follow one simple command, such as "Come here", "Give it to me", or "Put it back", without your using gestures?  
3. 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.)  
4. When you ask, "Where is the ball?" does your baby look at the object? Make sure the object is present? Check "yes" if he knows one object.  
5. When your baby wants something, does she tell you by pointing to it?  
6. Does your baby shake his head when he means "no" or "yes"?  
        Communication Total: 
 

Gross Motor

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
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?
 
2. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?  
3. Does your baby walk beside furniture while holding on with only one hand?  
4. If you hold both hands just to balance him, does your baby take several steps without tripping or falling? (If your baby already walks alone, check "yes" for this item.)
 
5. When you hold one hand just to balance her, does your baby take several steps forward? (If your baby already walks alone, check "yes" for this item.)
 
6. Does your baby stand up in the middle of the floor by himself/herself and take several steps forward?  
        Gross Motor Total:

 
 

   


Fine Motor

Be sure to try each activity with your child.


 
  YES SOMETIMES NOT YET  
1. After one or two tries, does your baby pick up a piece of string with his/her first finger and thumb? (The string may be attached to a toy)
 
2. Does your baby pick up a crumb or Cheerios with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it.
 
3. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?  
4. Without resting his arm or hand on the table, does your baby pick up a crumb or Cheerio with the tip of his thumb and a finger?
 
5. Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, check "not yet" for this item.)
 
6. Does your baby help turn the pages of a book?  
        Fine Motor Total:
 

Problem Solving

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. While holding a small toy in each hand, does your baby clap the toys together (like "Pat-a-cake")?  
2. 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)?  
3. 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)  
4. 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, check "yes" for this item.)  
5. Does your baby drop two small toys, one after another, into a container like a bowl or box?
 
6. After you scribble back and forth on a paper with a crayon (or a pencil or pen), does your baby copy by scribbling? (If she already scribbles on her own, check "yes" for this item.)  
        Problem Solving Total:
 

 

Personal-Social

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. When you hold out your hand and ask for a 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 our hand, mark "yes" for this item)  
2.  When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?   
3. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?  
4. When you dress her, does your baby lift her foot for her shoe, sock, or pant leg?  
5. Does your baby roll or throw a ball back to you so that you can return it to him?  
6. Does your baby play with a doll or stuffed anymal by hugging it?  
        Personal-social Total: 
 

Overall

Parents and providers may use the back of this sheet for additional comments.
1. Do you think your child hears well? YES NO If no, explain:
2. Does your baby use both hands equally well? YES NO If no, explain:
3. When your baby is standing, are her feet flat on the surface most of the time? 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: