April 19, 202111-12 Months – Developmental Questionnaire This quiz should take a maximum of 5 minutes. The final question will allow you to add comments for any questions you have not discussed or covered in the quiz. Depending on the child’s age within the range, answering “NO” isn’t necessarily a cause for concern. The difference between a 2 week old and a 2-month-old is significant. With that in mind, we will ask about your child's birthday and have a specialist look over your responses. We are happy to reach out to you if there's anything we see that the computer may have overlooked. First Name Last Name Zip Code Your Email Phone Number w/ Area Code Child's Age (e.g. 11.5 months) [Physical Developmental Skills] My child is able to stand without support for at least 5 seconds. Yes No [Physical Developmental Skills] My child can walk with one hand held. Yes No [Physical Developmental Skills] My child can take multiple steps without help or support. Yes No [Physical Developmental Skills] My child can lower to sit with support. Yes No 1 out of 3 [Occupational Developmental Skills] My child can pick up tiny objects with their thumb and pointer finger. Yes No [Occupational Developmental Skills] My child can explore boxes by lifting lids. Yes No [Occupational Developmental Skills] My child turns pages of books, but not necessarily one at a time. Yes No [Occupational Developmental Skills] My child likes to poke and touch different objects and textures. Yes No [Occupational Developmental Skills] My child is starting to use and explore utensils while eating. Yes No [Occupational Developmental Skills] My child will turn around/look at familiar objects when named. (Bottle, Mama, Etc) Yes No 2 out of 3 [Speech Developmental Skills] My child can follow sounds by turning their head. Yes No [Speech Developmental Skills] My child shows interest when I'm talking to them. Yes No [Speech Developmental Skills] My child vocalizes to get attention. Yes No [Speech Developmental Skills] My child might point or use gestures to communicate. Yes No [Speech Developmental Skills] My child recognizes commonly used words. (bottle, juice, etc.) Yes No [Speech Developmental Skills] My child smiles during a game of peek-a-boo. Yes No [Speech Developmental Skills] My child imitates some of my sounds. Yes No 3 out of 3 Please fill in the comment box below. Time's up
