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? What is the most important thing I should 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? Please make comments about anything else you think I need to 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 Communication Without giving your child help by pointing or using gestures, ask him to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly? When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, “barking,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?” Show your child how a zip on a coat moves up and down, and say, “See, this goes up and down.” Put the zip to the middle, and ask your child to move the zip down. Return the zip to the middle, and ask your child to move the zip up. Do this several times, placing the zip in the middle before asking your child to move it up or down. Does your child consistently move the zip up when you say “up” and down when you say “down”? When you ask, “What is your name?” does your child say both her first and last names? Without giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, “Clap your hands, walk to the door, and sit down,” or “Give me the pen, open the book, and stand up.” Does your child use all of the words in a sentence (for example, “a,” “the,” “am,” “is,” and “are”) to make complete sentences such as “I am going to the park,” or “Is there a toy to play with?” or “Are you coming, too?” Communication Total GROSS MOTOR Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the handrail or the wall. (You can look for this in a shop, in a playground, or at home.) Does your child stand on one foot for about 1 second without holding on to anything? While standing, does your child throw a ball overarm by raising his arm to shoulder height and throwing the ball forward? (Dropping the ball or throwing the ball underarm should be scored as “not yet.”) Does your child jump forward at least 6 inches with both feet leaving the ground at the same time? Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.) Does your child climb the runs of a ladder of a playground slide and slide down without help? GROSS MOTOR TOTAL FINE MOTOR After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle? After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction? Does your child try to cut paper with child-safe scissors? He does not need to cut the paper but must get the blades to open and close while holding the paper with the other hand. (You may show your child how to use scissors. Carefully watch your child’s use of scissors for safety reasons.) When drawing, does your child hold a pencil, crayon, or pen between her fingers and thumb like an adult does? Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalogue and cut it into six pieces. Does your child put it back together correctly?) Using the shape on the right to look at, does your child copy it onto a large piece of paper using a pencil, crayon, or pen, without tracing? (Your child’s drawing should look like the design of the shape, except it may be different in size.) FINE MOTOR TOTAL PROBLEM SOLVING When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”) Please write your child’s response here: When you say, “Say, ‘seven three,’” does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary try another pair of numbers and say, “Say, ‘eight two.’” (Your child must repeat just one series of two numbers for you to answer “yes” to this question.) Show your child how to make a bridge with blocks, boxes, or cans, like the example. Does your child copy you by making one like it? When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers for you to answer “yes” to this question.) When asked, “Which circle is the smallest?” does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.) Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mummy, daddy, brother, or sister, or an imaginary animal or figure. PROBLEM SOLVING TOTAL PERSONAL-SOCIAL When your child is looking in a mirror and you ask, “Who is in the mirror?” does he say either “me” or his own name? Does your child put on a coat, jacket, or shirt by himself? Using these exact words, ask your child, “Are you a girl or a boy?” Does your child answer correctly? Does your child take turns by waiting while another child or adult takes a turn? Does your child serve himself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop up something like fruit salad, yoghurt, or sauce into a bowl? Does your child wash his hands using soap and water and dry them with a towel without help? 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: Can other people 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: