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 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 four- and five-word sentences? For example, does your child say, “I want the car”? Please write an example: When talking about something that already happened, does your child use words that end in “-ed,” such as “walked,” “jumped,” or “played”? Ask your child questions, such as “How did you get to the store?” (“We walked.”) “What did you do at your friend’s house?” (“We played.”) Please write an example: Does your child use comparison words, such as “heavier,” “stronger,” or “shorter”? Ask your child questions, such as “A car is big, but a bus is ” (bigger); “A cat is heavy, but a man is ” (heavier); “A TV is small, but a book is ” (smaller). Please write an example: Does your child answer the following questions? (Mark “sometimes” if your child answers only one question.) “What do you do when you are hungry?” (Acceptable answers include “get food,” “eat,” “ask for something to eat,” and “have a snack.”) “What do you do when you are tired?” (Acceptable answers include: “take a nap,” “rest,” “go to sleep,” “go to bed,” “lie down,” and “sit down.”) Please write your child’s response: Please write an example: Does your child repeat the sentences shown below back to you, with- out any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark “yes” if your child repeats both sen- tences without mistakes or “sometimes” if your child repeats one sen- tence without mistakes.) Jane hides her shoes for Maria to find. Al read the blue book under his bed. Communication Total GROSS MOTOR While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”) 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.) Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.) Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.) Does your child hop forward on one foot for a distance of 4–6 feet without putting down the other foot? (You may give her two tries on each foot. Mark “sometimes” if she can hop on one foot only.) Does your child skip using alternating feet? (You may show him how to do this.) GROSS MOTOR TOTAL FINE MOTOR Ask your child to trace on the line below with a pencil. Does your child trace on the line without going off the line more than two times? (Mark “sometimes” if your child goes off the line three times.) Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, “Draw a picture of a girl or a boy.” If your child draws a person with head, body, arms, and legs, mark “yes.” If your child draws a person with only three parts (head, body, arms, or legs), mark “sometimes.” If your child draws a person with two or fewer parts (head, body, arms, or legs), mark “not yet.” Be sure to include the sheet of paper with your child’s drawing with this questionnaire Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.) Using the shapes below to look at, does your child copy the shapes in the space below without tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size. Mark “yes” if she copies all three shapes; mark “sometimes” if your child copies two shapes.) Using the letters below to look at, does your child copy the letters without tracing? Cover up all of the letters except the letter being copied. (Mark “yes” if your child copies four of the letters and you can read them. Mark “sometimes” if your child copies two or three letters and you can read them.) Print your child’s first name. Can your child copy the letters? The letters may be large, backward, or reversed. (Mark “sometimes” if your child copies about half of the letters.) FINE MOTOR TOTAL PROBLEM SOLVING When asked, “Which circle is smallest?” does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.) When shown objects and asked, “What color is this?” does your child name five different colors like red, blue, yellow, orange, black, white, or pink? (Mark “yes” only if your child answers the question correctly using five colors.) Does your child count up to 15 without making mistakes? If so, mark “yes.” If your child counts to 12 without making mistakes, mark “sometimes. Does your child finish the following sentences using a word that means the opposite of the word that is italicized? For example: “A rock is hard, and a pillow is soft.” Please write your child’s responses below: A cow is big, and a mouse is Ice is cold, and fire is We see stars at night, and we see the sun during the When I throw the ball up, it comes (Mark “yes” if he finishes three of four sentences correctly. Mark “sometimes” if he finishes two of four sentences correctly.) Please write your child’s response here: Does your child know the names of numbers? (Mark “yes” if she identi- fies the three numbers below. Mark “sometimes” if she identifies two numbers.) Does your child name at least four letters in her name? Point to the letters and ask, “What letter is this?” (Point to the letters out of order.) PROBLEM SOLVING TOTAL PERSONAL-SOCIAL Can your child serve himself, taking food from one container to another, using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl? Does your child wash his hands using soap and water and dry them with a towel without help? Does your child tell you at least four of the following? 1. First name 2. Age 3. City he lives in 4. Last name 5. Boy or girl 6. Telephone number Does your child dress and undress himself, including buttoning medium-size buttons and zipping front zippers? Does your child use the toilet by herself? (She goes to the bathroom, sits on the toilet, wipes, and flushes.) Mark “yes” even if she does this after you remind her. Does your child usually take turns and share with other children? 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 children 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: