April 20, 20216-12 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. 8 years, 4 months) [Physical Developmental Skills] My child can catch a ball with hands only. Yes No [Physical Developmental Skills] My child can throw a ball overhead 10 feet. Yes No [Physical Developmental Skills] My child can dribble a ball. Yes No [Physical Developmental Skills] My child is starting to or has mastered riding a bike. Yes No [Physical Developmental Skills] My child can do jumping jacks. Yes No [Physical Developmental Skills] My child can participate in PE at the same capacity as others. Yes No 1 out of 3 [Occupational Developmental Skills] My child can copy all simple shapes. (circle, square, triangle, etc.) Yes No [Occupational Developmental Skills] My child can play organized games with peers. Yes No [Occupational Developmental Skills] My child can use a knife to spread jelly or peanut butter. Yes No [Occupational Developmental Skills] My child can brush their own teeth and hair. Yes No [Occupational Developmental Skills] My child is starting to participate in household chores like cleaning their room. Yes No [Occupational Developmental Skills] My child has a preferred peer. Yes No [Occupational Developmental Skills] My child displays appropriate emotions. Yes No [Occupational Developmental Skills] My child can dress themselves. Yes No [Occupational Developmental Skills] My child can tie their shoes. Yes No [Occupational Developmental Skills] My child can write the alphabet and numbers 1-10. Yes No [Occupational Developmental Skills] My child can keep up with homework tasks. Yes No 2 out of 3 [Speech Developmental Skills] My child can answer/complex simple yes or no questions. Yes No [Speech Developmental Skills] My child is interested in conversations. Yes No [Speech Developmental Skills] My child can identify rhyming words. Yes No [Speech Developmental Skills] My child can identify opposites. Yes No [Speech Developmental Skills] My child can follow instructions. Yes No [Speech Developmental Skills] My child can answer how, when, and why questions. Yes No [Speech Developmental Skills] My child can recall and answer questions from a book. Yes No [Speech Developmental Skills] My child can retell stories in sequential orders. Yes No [Speech Developmental Skills] My child asks for clarification. Yes No [Speech Developmental Skills] My child can start and maintain conversations. Yes No [Speech Developmental Skills] My child can write sentences. Yes No [Speech Developmental Skills] My child can make inferences based on a story or situation. Yes No 3 out of 3 Please fill in the comment box below. Time's up
