30 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 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?  
2. 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.)  
3. Without giving her clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?
  
a. "Put the toy on the table." d. "Find your coat."
b. "Close the door." e. "Take my hand."
c. "Bring me a towel." f. "Get your book."

 
 
4. Does your child make sentences that are three or four words long? Please give an example:
 
5. 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?  
6. 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?”  
        Communication Total: 
 

Gross Motor

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. Does your child walk down stairs if you hold onto one of his hands?  
2. Does your child stand on one foot for about 1 second without holding onto anything?
 
 
3.  Does your child walk either up or down at least two steps by himself? He may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
 
4. Does your child run fairly well, stopping herself without bumping into things or falling?
 
5.  Does your child jump with both feet leaving the floor at the same time?
 
6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
 
        Gross Motor Total:

 
 

   


Fine Motor

Be sure to try each activity with your child.


 
  YES SOMETIMES NOT YET  
1. Does your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?  
2. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, 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?
 
3. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
 
4. 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?
 
5. 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?
 
6. Does your child turn pages in a book, one page at a time?
 
 
        Fine Motor Total:
 

Problem Solving

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. When looking in the mirror, ask, “Where is _______?” (Use your child’s name.) Does your child point to her image in the mirror?
 
 
2.  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)?  
3. 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.)
 
4. 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.”)

Please write your child's response below:
 
5. 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.  
6.  After your child draws a “picture,” even a simple scribble, does she tell you what she drew? (You may say, “Tell me about your picture,” or ask, “What is this?” to prompt her.)
 
 
        Problem Solving Total:
 

 

Personal-Social

Be sure to try each activity with your child.
  YES SOMETIMES NOT YET  
1. If you do any of the following gestures, does your child copy at least one of them?
  • Open and close your mouth.
  • Pull on your earlobe.
  • Blink your eyes.
  • Pat your cheek.
 
2. Does your child use a spoon to feed himself with little spilling?  
3. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she cannot turn?  
4. Does your child put on a coat, jacket, or shirt by himself?  
5. After you put on loose-fitting pants around her feet, does your child pull them completely up to her waist?  
6. 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?  
        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:
9. Can other people understand most of what your child says? If no, explain: YES NO If yes, explain:
10. Do you have any concerns about your child’s behavior? If yes, explain: YES NO If yes, explain: