Developmental Screening Questionnaire

12 Months of age

Child’s name: __________________________________ Date: ____________

Age: _________________ DOB: _______________

Fine Motor

Q1: Does your child pick up some object with a finger and thumb grasp?

A: Never B: Sometimes C: Always

Q2: Does your child throw an object forward?

A: Never B: Sometimes C: Always

Q3: Can your child pick up small bits of food?

A: Never B: Sometimes C: Always

Q4: Can you child pick and put down a small toy without dropping it?

A: Never B: Sometimes C: Always

Q5: Do you have any Fine Motor concerns beyond the questions asked?

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Gross Motor

Q6: Can your child get into a sitting position without help?

A: Never B: Sometimes C: Always

Q7: Can your child pull themselves up to a standing position at the couch?

A: Never B: Sometimes C: Always

Q8: Can your child walk a few steps while holding onto furniture?

A: Never B: Sometimes C: Always

Q9: Can your child stand unaided for more approximately 5 seconds?

A: Never B: Sometimes C: Always

Q10: Do you have any Gross Motor concerns beyond the questions asked?

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Communication:

Q11: Does your child respond to the sound of your voice when you say their name?

A: Never B: Sometimes C: Always

Q12: Does your child follow simple routine directions?

A: Never B: Sometimes C: Always

Q13: Does your child say words such as ‘mama’ ‘dada’ and ‘baba’?

A: Never B: Sometimes C: Always

Q14: Can your child imitate sounds for simple games such as peek-a-boo?

A: Never B: Sometimes C: Always

Q15: Do you have any Communication concerns beyond the questions asked?

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Problem Solving:

Q16: Can your child put objects in and out of containers?

A: Never B: Sometimes C: Always

Q17: Does your child attempt to imitate you in activities such as simple puzzles?

A: Never B: Sometimes C: Always

Q18: If you hide an object behind your back, does your child show interest in finding it?
A: Never B: Sometimes C: Always

Q19: If you put a small piece of food inside a container, will your child turn the container upside

down to get the food out?

A: Never B: Sometimes C: Always

Q20: Do you have any Problem Solving concerns beyond the questions asked?

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Adaptive:

Q21: Does your child use household objects correctly such as their toothbrush or a cup?

A: Never B: Sometimes C: Always

Q22: If you hand your child an item upside down will they turn it right side up?

A: Never B: Sometimes C: Always

Q23: Does your child assist with dressing by lifting their arms and legs?

A: Never B: Sometimes C: Always

Q24: Will your child reach for their cup or bottle when hungry or thirsty?

A: Never B: Sometimes C: Always

Q25: Do you have any Adaptive concerns beyond the questions asked?

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Social Emotional:

Q26: Is your child shy with unfamiliar people?

A: Never B: Sometimes C: Always

Q27: Is your child able to self-sooth within a short amount of time after becoming upset?
A: Never B: Sometimes C: Always

Q28: Does your child play games such as peek-a-boo or pat-a-cake?

A: Never B: Sometimes C: Always

Q29: Does your child imitate sounds or gestures to get your attention?

A: Never B: Sometimes C: Always

Q30: Do you have any Social Emotional concerns beyond the questions asked?

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