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Screening

This document contains a developmental screening questionnaire for a child aged 12 months. It includes questions about the child's fine motor, gross motor, communication, problem solving, adaptive, and social emotional skills. Parents are asked to answer each question by selecting either "Never", "Sometimes", or "Always" to indicate the child's ability level. Space is also provided after each section for parents to note any additional concerns.

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68 views

Screening

This document contains a developmental screening questionnaire for a child aged 12 months. It includes questions about the child's fine motor, gross motor, communication, problem solving, adaptive, and social emotional skills. Parents are asked to answer each question by selecting either "Never", "Sometimes", or "Always" to indicate the child's ability level. Space is also provided after each section for parents to note any additional concerns.

Uploaded by

api-381712991
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Developmental Screening Questionnaire

12 Months of age

Child’s name: __________________________________ Date: ____________

Age: _________________ DOB: _______________

Fine Motor

Q1: Does your child pick up some object with a finger and thumb grasp?

A: Never B: Sometimes C: Always

Q2: Does your child throw an object forward?

A: Never B: Sometimes C: Always

Q3: Can your child pick up small bits of food?

A: Never B: Sometimes C: Always

Q4: Can you child pick and put down a small toy without dropping it?

A: Never B: Sometimes C: Always

Q5: Do you have any Fine Motor concerns beyond the questions asked?

______________________________________________________________________________

______________________________________________________________________________

Gross Motor

Q6: Can your child get into a sitting position without help?

A: Never B: Sometimes C: Always

Q7: Can your child pull themselves up to a standing position at the couch?

A: Never B: Sometimes C: Always

Q8: Can your child walk a few steps while holding onto furniture?

A: Never B: Sometimes C: Always


Q9: Can your child stand unaided for more approximately 5 seconds?

A: Never B: Sometimes C: Always

Q10: Do you have any Gross Motor concerns beyond the questions asked?

______________________________________________________________________________

______________________________________________________________________________

Communication:

Q11: Does your child respond to the sound of your voice when you say their name?

A: Never B: Sometimes C: Always

Q12: Does your child follow simple routine directions?

A: Never B: Sometimes C: Always

Q13: Does your child say words such as ‘mama’ ‘dada’ and ‘baba’?

A: Never B: Sometimes C: Always

Q14: Can your child imitate sounds for simple games such as peek-a-boo?

A: Never B: Sometimes C: Always

Q15: Do you have any Communication concerns beyond the questions asked?

______________________________________________________________________________

______________________________________________________________________________

Problem Solving:

Q16: Can your child put objects in and out of containers?

A: Never B: Sometimes C: Always

Q17: Does your child attempt to imitate you in activities such as simple puzzles?

A: Never B: Sometimes C: Always

Q18: If you hide an object behind your back, does your child show interest in finding it?
A: Never B: Sometimes C: Always

Q19: If you put a small piece of food inside a container, will your child turn the container upside

down to get the food out?

A: Never B: Sometimes C: Always

Q20: Do you have any Problem Solving concerns beyond the questions asked?

______________________________________________________________________________

______________________________________________________________________________

Adaptive:

Q21: Does your child use household objects correctly such as their toothbrush or a cup?

A: Never B: Sometimes C: Always

Q22: If you hand your child an item upside down will they turn it right side up?

A: Never B: Sometimes C: Always

Q23: Does your child assist with dressing by lifting their arms and legs?

A: Never B: Sometimes C: Always

Q24: Will your child reach for their cup or bottle when hungry or thirsty?

A: Never B: Sometimes C: Always

Q25: Do you have any Adaptive concerns beyond the questions asked?

______________________________________________________________________________

______________________________________________________________________________

Social Emotional:

Q26: Is your child shy with unfamiliar people?

A: Never B: Sometimes C: Always

Q27: Is your child able to self-sooth within a short amount of time after becoming upset?
A: Never B: Sometimes C: Always

Q28: Does your child play games such as peek-a-boo or pat-a-cake?

A: Never B: Sometimes C: Always

Q29: Does your child imitate sounds or gestures to get your attention?

A: Never B: Sometimes C: Always

Q30: Do you have any Social Emotional concerns beyond the questions asked?

______________________________________________________________________________

______________________________________________________________________________

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