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2 MONTH QUESTIONNAIRE
Score Summary

COMMUNICATION (Max Score : 60, Cutoff: 22.77)

[FIELD3 + FIELD4 + FIELD6 + FIELD7 + FIELD8 + FIELD9] 

GROSS MOTOR (Max Score : 60, Cutoff: 41.84)

[FIELD14 + FIELD15 + FIELD16 + FIELD17 + FIELD18 + FIELD19]

FINE MOTOR (Max Score : 60, Cutoff: 30.16)

[FIELD30 + FIELD31 + FIELD32 + FIELD33 + FIELD34 + FIELD35]

PROBLEM SOLVING (Max Score : 60, Cutoff: 24.62)

[FIELD47 + FIELD48 + FIELD49 + FIELD50 + FIELD51 + FIELD52]

PERSONAL-SOCIAL (Max Score : 60, Cutoff: 33.71)

[FIELD56 + FIELD57 + FIELD58 + FIELD59 + FIELD60 + FIELD61]

Child Details
Baby's Namefull name (first middle last)
Date of Birthbaby's date of birth
date_range
Completion Datedate you completed this questionnaire
date_range
Providerselect a provider
Is baby premature?premature by how many months

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.

COMMUNICATION

Please try each activity with your child

Does your baby sometimes make throaty or gurgling sounds?
Does your baby make cooing sounds such as "ooo", "gah", "aah"?
When you speak to your baby, does she/he make sounds back to you?
Does your baby smile when you talk to him/her?
Does your baby chuckle softly?
After you have been out of sight, does your baby smile or get excited when she/he sees you?

COMMUNICATION TOTAL: 

[FIELD3 + FIELD4 + FIELD6 + FIELD7 + FIELD8 + FIELD9]

GROSS MOTOR

Please try each activity with your child

While your baby is on their back, does he/she wave their arms and legs, wiggle, and squirm?
When your baby is on their tummy, does she/he turn their head to the side?
When your baby is on his/her tummy, does he/she hold their head up longer than a few seconds?
When your baby is on her/his back, does she/he kick their legs?
While your baby is on their back, does he/she move head from side to side?
After holding her/his head up while on their tummy, does your baby lay head back down on the floor, rather than let it drop or fall forward?

GROSS MOTOR TOTAL:

[FIELD14 + FIELD15 + FIELD16 + FIELD17 + FIELD18 + FIELD19]


FINE MOTOR

Please try each activity with your child

Is your baby's hand usually tightly closed when he/she is awake? (If your baby is used to do this but no longer does, mark "yes").
Does your baby grasp your finger if you touch the palm of her/his hand?
When you put a toy on your baby's hand, does he/she hold it in their hand briefly?
Does your baby touch her/his face with their hands?
Does your baby hold his/her hands open or partly open when awake (rather than in fists, as they were when he/she was a new born)?
Does your baby grab or scratch at her/his clothes?

FINE MOTOR TOTAL:

[FIELD30 + FIELD31 + FIELD32 + FIELD33 + FIELD34 + FIELD35]

PROBLEM SOLVING

Please try each activity with your child

Does your baby look at objects that are 8-10 inches away?
When you move around, does your baby follow you with their eyes?
When you move a toy slowly from side to side in front of your baby's face (about 10 inches away), does your baby follow the toy with their eyes, sometimes turning their head?
When you move a small toy up and down slowly in front of your baby's face (about 10 inches away), does your baby follow the toy with their eyes?
When you hold your baby in a sitting position, does she/he look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?
When you dangle a toy above your baby while he/she is lying on their back, does they wave their arms towards the toy?

PROBLEM SOLVING TOTAL:

[FIELD47 + FIELD48 + FIELD49 + FIELD50 + FIELD51 + FIELD52]

PERSONAL-SOCIAL

Please try each activity with your child

Does your baby sometimes try to suck, even when he/she's not feeding?
Does your baby cry when he/she is hungry, wet, tired, or wants to be held?
Does your baby smile at you?
When you smile at your baby, does she/he smile back?
Does your baby watch his hands?
When your baby sees the breast or bottle, does he/she seem to know she/he is about to be fed?

PERSONAL-SOCIAL TOTAL:

[FIELD56 + FIELD57 + FIELD58 + FIELD59 + FIELD60 + FIELD61]

OVERALL
Did your baby pass the newborn hearing screening test?
If no, explain (only allows alphabets, numbers and spaces)
Does your baby move both hands and both legs equally well?
If no, explain (only allows alphabets, numbers and spaces)
Does either parent have a family history of childhood deafness or hearing impairment, or vision problems?
If yes, explain (only allows alphabets, numbers and spaces)
Has your baby had any medical problems?
If yes, explain (only allows alphabets, numbers and spaces)
Do you have concerns about your baby's behavior (for example, eating, sleeping)?
If yes, explain (only allows alphabets, numbers and spaces)
Does anything about your baby worry you?
If yes, explain (only allows alphabets, numbers and spaces)
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