Please help us get to know your child by filling out this form. All the information will be confidential. We will use what you tell us as we begin to get to know your child and p l a n wa y s t o m eet hi s / h er n e e d s and t o h e l p h i m /h er develop. Please return it to school as soon as possible. Thanks so much! Child's Name Child's Nickname Parents’ Names Date
Date Format: MM slash DD slash YYYY
Child’s Teacher Does your child live with? Please Specify Please list the names and ages of others who live in your home. (This will help me write names correctly on pictures your child draws about his/her family.) Pets (Name & type of animal) Father’s Occupation Mother's Occupation Does your child have a room of his own? If not, with whom does he/she share a room? What are your child’s favourite play activities and interests? Does child use special words to go to the bathroom? Child’s favorite TV programs Hours per day spent watching TV Does your child usually play Does child have decided fears? If so, what? What responsibilities does your child have at home? What is your biggest discipline problem? How do you discipline your child? What is your child’s favorite story or type of story or book? Did your child have a premature or difficult birth that may indicate cognitive delays? Is English your child’s first language? If not, what is? Is English the primary language spoken in the home? If not, what is? Does your child speak any English? Understand English? How does your child feel about coming to school? What do you hope your child will learn this year? Please make comments about anything else you think I need to know about your child It is our goal to encourage a sense of belongingness, promote an appreciation of others and enrich children’s experiences by integrating into our curriculum activities and information that reflect our individual children’s background. One way we can do this is by learning about each child’s family background, celebrated holidays, and traditions. Please take a few minutes to share with us your special family days or activities and how they are carried out in your home. What languages other than English are spoken by family members around your child? Does your child have any physical or learning disabilities? If so, please describe Are there any family members with disabilities that may directly impact your child’s daily life (for example, a deaf grandparent, wheelchair bound parent, etc.)? What information about your family’s background and culture would you like to share with us? What are the holidays, special days, or traditions your family partakes in? Are there any special foods, songs, items or symbols you include in your celebration of special family times? Does your child have any dietary restrictions due to allergies, intolerances, family or religious preferences? If yes, what is restricted? Are there any activities from your family’s culture or traditions that you would like to share with your child’s classroom? What is the most important thing I should know about your child? What are their strengths? What are the areas of weakness? What would you love for your child to get better at? My child learns best when the teacher is…. My child does not work well with… What is the best way to motivate your child? What are you looking forward to at YMIM? How would you like to be involved with your child’s education? What is your preferred method of communication (email, phone call, meeting, note…) Child’s date of birth:
Date Format: MM slash DD slash YYYY
Is It a Boy Or a Girl? Email
Date ASQ-3 completed by parent/caregiver:
Date Format: MM slash DD slash YYYY
Date of review with health professional:
Date Format: MM slash DD slash YYYY
Child’s home address Town Postcode Person completing the questionnaire Relationship to child: Home tel: Mobile no.:
All children develop at different rates and in different ways. Please do not worry if your child is not doing all or any of the activities mentioned in the questionnaire. It is not a test. The activities are simply one way of understanding how your child is progressing
Yes = your child does this activity (or has done it and has now progressed, e.g., crawling, but is now walking)
Sometimes = your child is just beginning to do this activity (but does not do it regularly)
Not Yet = your child has not yet started doing this.
Please leave blank any activities your child has not been able to try with you
Important Points to Remember:
Try each activity with your child before marking a response.
Make completing this questionnaire a game that is fun for you and your child.
Make sure your child is not tired or hungry.
Please bring this questionnaire with you to your child’s health and development review. Additional Notes
At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your child more than one time. If possible, try the activities when your child is cooperative. If your child can do the activity but refuses, mark “yes” for the item.
Communication Without showing him, does your child point to the correct picture when you say, “Show me the cat,” or ask, “Where is the dog?” (She needs to identify only one picture correctly.) Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as “Mama eat,” “Daddy play,” “Go home,” or “What’s this?” Does your child say both words back to you? (Mark “yes” even if her words are difficult to understand.) Without giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions? 1. “Put the toy on the table.” 2. “Close the door.” 3.“Bring me a towel.” 4. “Find your coat.” 5.“Take my hand.” 6. “Get your book.” If you point to a picture of a ball (cat, cup, hat, etc.) and ask your child, “What is this?” does your child correctly name at least one picture? Does your child say two or three words that represent different ideas together, such as “See dog,” “Mummy come home,” or “Cat gone”? (Don’t count word combinations that express one idea, such as “byebye,” “all gone,” “all right,” or “What’s that?”) Please give an example of your child’s word combinations: Does your child correctly use at least two words like “me,” “I,” “mine,” and “you”? Communication Total GROSS MOTOR Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the handrail or wall. (You can look for this in a shop, in a playground, or at home.) When you show your child how to kick a large ball, does he try to kick the ball either by moving his leg forward or by walking into it? (If your child already kicks a ball, mark “yes” for this item.) Does your child walk either up or down at least two steps by herself? She may hold onto the handrail or wall. Does your child run fairly well, stopping herself without bumping into things or falling over? Does your child jump with both feet leaving the floor at the same time? Without holding onto anything for support, does your child kick a ball by swinging his leg forward? GROSS MOTOR TOTAL FINE MOTOR Does your child get a spoon into his mouth right side up so that the food usually doesn’t spill? Does your child turn the pages of a book by herself? (She may turn more than one page at a time.) Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars? Does your child flip switches off and on? Does your child stack seven small blocks or toys on top of each other by herself? (You could also use cotton reels, small boxes, or toys that are about 1 inch in size.) Can your child string small items such as pasta or beads onto a string or shoelace? (Carefully watch your child’s use of beads and strings for safety reasons.) FINE MOTOR TOTAL PROBLEM SOLVING After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark “not yet” if your child scribbles back and forth.) After a raisin is dropped into a clear plastic bottle, does your child turn the bottle upside down to tip out the raisin? (Do not show him how.) (You can use a small water bottle or baby bottle.) Does your child pretend objects are something else? For example, does your child hold a cup to her ear, pretending it is a telephone? Does she put a box on her head, pretending it is a hat? Does she use a block or a small toy to stir food? Does your child put things away where they belong? For example, does he know his toys belong on the toy shelf, his blanket goes on his bed, and dishes go in the kitchen? If your child wants something they cannot reach, do they find a chair or box to stand on to reach it (for example, to reach a toy on a table or worktop or to “help” you in the kitchen)? While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use cotton reels, small boxes, or other toys.) PROBLEM SOLVING TOTAL PERSONAL-SOCIAL Does your child drink from a cup or glass, putting it down again with little spilling? Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair? Does your child eat with a knife/spoon and fork? When playing with either a soft toy or a doll, does your child cuddle it, pretend to feed it, put it to bed, etc.? Does your child push a little truck, doll’s buggy, or other toy on wheels, steering it around objects and backing out of corners if he cannot turn? Does your child call herself “I” or “me” more often than their own name? For example, “I do it,” more often than “Emily do it.” PERSONAL-SOCIAL TOTAL OVERALL
Parents and providers may use the space below for additional comments.
Do you think your child hears well? If no, explain Do you think your child talks like other toddlers her age? If no, explain: Can you understand most of what your child says? If no, explain: Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain: Does either parent have a family history of childhood deafness or hearing problems? If yes, explain: Do you have concerns about your child’s eyesight? If yes, explain: Has your child had any medical or health-related problems in the last few months? If yes, explain: Do you have any concerns about your child’s behaviour? If yes, explain: Does anything about your child worry you? If yes, explain: