18 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. When your child wants something, does she tell you by pointing to it?  
2. When you ask him to, does your child 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")  
3. Does your child say eight or more words in addition to "Mama" and "Dada"?  
4. 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? (Check "yes" even if her words are hard to understand.)  
5. Without showing him first, does your child point to the correct picture when you say, "Show me the kitty" or ask, "Where is the dog?" (He needs to indentify only one picture correctly.)  
6. 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," "What's that?")  
Please give an example of your child's word combinations:
      Communication Total: 
 

Gross Motor

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?  
2. Does your child move around by walking, rather than by crawling on her hands and knees?  
3. Does your child walk well and seldom fall?  
4. Does your child climb on an object such as a chair to reach something he wants?  
5. Does your child walk down stairs if you hold onto one of her hands? (You can look for this at a store, on a playground, or at home.)  
6. When you show him how to kick a large ball, does your child try to kick the ball by moving his leg forward or by walking into it? (If your child already kicks a ball, check "yes" for this item)
 
        Gross Motor Total:

 
 

   


Fine Motor

Be sure to try each activity with your child.


 
  YES SOMETIMES NOT YET  
1. Does your child throw a small ball with a forward arm motion? (If he simply drops the ball, check "not yet" for this item.)
 
2. 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 one inch in size.)  
3. Does your child make a mark on paper with the tip of a crayon, pencil, or pen when trying to draw?
 
4. Does your child stack three 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 one inch in size.)  
5. Does your child turn the pages of a book by himself? (He may turn more than one page at a time)  
6. Does your child get a spoon into her mouth right side up so that the food doesn't usually spill?  
        Fine Motor Total:
 

Problem Solving

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. Does your child drop several (six or more) small toys into a container, such as a bowl or box? (You may show him how to do it.)  
2. After you have shown her how, does your child try to get a small toy that is slightly out of reach by using the spoon, stick, or similar tool?
 
3. After a crumb or Cheerio is dropped into a bottle, does your child purposely turn the bottle over to dump it out? You may show him how to do this. You can use a plastic sode-pop bottle or baby bottle.   
4. Without first showing her how, does your child scribble back and forth when you give her a crayon, pen, or pencil?  
5. After he watched you draw a line from the top of the paper to the bottom with a crayon, pen, or pencil, does your child copy you by drawing a single line on the paper in any direction? (Scribbling back and forth does not count as a "yes")
 
6. 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 her how)  
        Problem Solving Total:
 

 

Personal-Social

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. While looking at himself in the mirror, does your child offer a toy to his own image?  
2.  Does your child play with a doll or stuffed animal by hugging it?   
3. Does your child get your attention or try to show you something by pulling on your hand or clothes?  
4. Does your child come up to you when she needs help, such as with winding up a toy?  
5. Does your child drink from a cup or glass, putting it down again with little spilling?  
6. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?  
        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. Do you think your child talks like other toddlers his age? YES NO If no, explain:
3. Can you understand most of what your child says? YES NO If no, explain:
4. Do you think your child walks, runs, and climbs like other toddlers her age? YES NO If no, explain:
5. Does either parent have a family history of childhood deafness or hearing impairment? YES NO If yes, explain:
6. Do you have concerns about your child's vision? YES NO If yes, explain:
7. Has your child had any medical problems in the last several months? YES NO If yes, explain:
8. Does anything about your baby worry you? YES NO If yes, explain: