36 Uonth Q,uestionnaire

pase6or7

OVERALL
Parents and providars may use the space below for additional comments.

1.

Do you think your child hears well? lf no, explain:

Oro

2.

Do you think your child talks like other children her age? lf no, explain:

O*o

Can you understand most of what your child says? lf no, explain:

Can other people understand most of what your child says? lf no, explain:

Do you think your child walks, runs, and climbs like other children his age? lf no, explain:

Does either parent have a family history of childhood deafness or hearing impairment? lf yes, explain:

E101360600

Ages & Stages Ouestionnaires@ Third Edition (ASO-3ru1, Squires & Bricker @ 2009 Paul H. Brookes Publishing Co. All rights reserved.