April 19, 20213-4 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. 3.5 months) [Physical Developmental Skills] My child holds their head up with control while on their belly. Yes No [Physical Developmental Skills] My child can raise both their head and chest when on their belly. Yes No [Physical Developmental Skills] My child can roll from their back to their belly. Yes No [Physical Developmental Skills] My child can sit with my support. Yes No [Physical Developmental Skills] My child's hands can meet together. Yes No [Physical Developmental Skills] My child can bring their hands to their mouth. Yes No [Physical Developmental Skills] My child can push down on legs when on a hard surface. Yes No 1 out of 3 [Occupational Developmental Skills] My child attempts to reach and grasp for objects. Yes No [Occupational Developmental Skills] My child touches their face, eyes, and mouth. Yes No [Occupational Developmental Skills] My child can accurately look toward sounds. Yes No [Occupational Developmental Skills] My child can recognize familiar faces and bottles. Yes No [Occupational Developmental Skills] My child watches people. Yes No [Occupational Developmental Skills] My child occasionally smiles at self in the mirror. Yes No [Occupational Developmental Skills] My child explores objects with mouth. Yes No [Occupational Developmental Skills] My child shakes rattle. Yes No [Occupational Developmental Skills] My child's eyes can move with moving objects. Yes No 2 out of 3 [Speech Developmental Skills] My child has different cries for different needs. Yes No [Speech Developmental Skills] My child smiles when spoken to. Yes No [Speech Developmental Skills] My child startles with loud noises. Yes No [Speech Developmental Skills] My child babbles. Yes No [Speech Developmental Skills] My child will follow sounds with their eyes. Yes No [Speech Developmental Skills] My child had started to copy some facial expressions. Yes No [Speech Developmental Skills] My child has started to imitate sounds that I make. Yes No 3 out of 3 Please fill in the comment box below. Time is Up! Time's up
