April 20, 20214-6 Years – 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. 4 years, 8 months) [Physical Developmental Skills] My child can go downstairs with alternating feet without handrail. Yes No [Physical Developmental Skills] My child can balance on one foot for 10 seconds. Yes No [Physical Developmental Skills] My child can hop on one foot at least 5 times. Yes No [Physical Developmental Skills] My child can catch a ball consistently. Yes No [Physical Developmental Skills] My child can throw a ball over head at least 10 feet. Yes No [Physical Developmental Skills] My child can gallop and skip. Yes No 1 out of 3 [Occupational Developmental Skills] My child can cut along a straight line sometimes. Yes No [Occupational Developmental Skills] My child can copy a triangle. Yes No [Occupational Developmental Skills] My child is beginning to play well with others. Yes No [Occupational Developmental Skills] My child can button and unbutton large buttons. Yes No [Occupational Developmental Skills] My child can dress themselves but may need help with buttons and zippers. Yes No [Occupational Developmental Skills] My child can do a task for a reward. Yes No [Occupational Developmental Skills] My child can zip their own jacket. Yes No [Occupational Developmental Skills] My child can recognize their name. Yes No [Occupational Developmental Skills] My child can write their name. Yes No 2 out of 3 [Speech Developmental Skills] My child listens and understands most of what is said at home/school. Yes No [Speech Developmental Skills] My child can label family members. Yes No [Speech Developmental Skills] My child can label family members. Yes No [Speech Developmental Skills] My child can identify rhyming words. Yes No [Speech Developmental Skills] My child speaks in 4+ word sentences. Yes No [Speech Developmental Skills] My child can tell or retell stories or events. Yes No [Speech Developmental Skills] My child can count to 10 and up. Yes No [Speech Developmental Skills] My child can identify rhyming words. Yes No [Speech Developmental Skills] My child can identify their own name, age, and gender. Yes No [Speech Developmental Skills] My child uses I, me, we, you, and they properly. Yes No [Speech Developmental Skills] My child can respond to what, where, and who questions. Yes No [Speech Developmental Skills] My child can use he, she, or they properly. Yes No 3 out of 3 Please fill in the comment box below. Time's up
