Development Questionnaire

Child's name:_____________________________________________________
Child's age:______________________________________________________
Date:_____________________________________________________________

Family Health History

For both parents' families, list any relevant health conditions, including mental and physical health,
seizure conditions, disabilities, and learning problems:
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Your Child's Health

List information about your child's growth, any disabling conditions, illnesses and treatments,
operations, accidents, immunizations, etc. If relevant, include your reactions:
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Family Separation

How often do you leave your child in another's care?

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1. What kind of childcare do you use (including babysitting)?

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2. How does your child react to being left with someone else?
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3. How do you feel about leaving your child with someone else?
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Feeding / Oral Behavior

1. Describe what and how your child eats:

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2. Describe any other oral behavior your child has (thumbsucking, pacifier use, mouthing toys or
other objects, biting, etc.) and your reactions:
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Sleep

1. Does your child have any sleep problems? Describe them:

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2. Describe your child's typical sleep / wake pattern (including naps):
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Activity and Motor Development

 1. Describe your child's gross and fine motor skills (how he moves around, grabs things, etc.).
Have you noticed anything unusual in this area?
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2. Are you concerned about your child's motor skills? Why?
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Social Skills and Environment

1. What, if anything, can your child do for himself?

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2. Can your child follow simple directions?
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3. How does your child react to family outings and visitors?
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4. Does your child participate in any social groups outside the home (daycare, playgroup, etc.)
Yes / No

Coping

1. Describe how your child copes with discomfort, frustration, or other distress:
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Language and Communication

1. Describe your child's language abilities (if your baby is under a year old, include any sounds
and words he makes; if he's older, include the extent of his vocabulary and whether he uses
word combinations, complete sentences, and / or pronouns such as he, she, and it):
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2. How do you encourage your child's language development (reading, talking, singing, etc.)?
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3. If your child isn't talking yet, how does he communicate his wishes?
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Toys and Play

1. List your child's favorite toys and describe how he plays with them:
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2. Does your child have a favorite toy / lovey? Yes / No
What is it? _______________________________________________________________
3. Does your child play on his own? Yes / No
4. Does your child play with other children? Yes / No
5. Does your child use his imagination when he plays? Yes / No

Feelings and Moods

1. Describe your child's range of feelings (comfort, discomfort, pleasure, joy, anger, affection,
fear, hostility, depression / sadness) and how he expresses them:
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2. What is likely to upset your child?
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3. What makes him feel better?
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Fears and Anxieties

1. What is your child afraid of?

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2. What isn't he afraid of?
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3. Does your child ever seem fearless when he does something dangerous? Yes / No
4. Does your child ever seem unusually sensitive to sounds, light, textures, or changes in routine?
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5. How do you -- and your child -- handle his anxieties?
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Aggressive Behavior

1. In what ways, if any, does your child behave aggressively toward you, his siblings, his
playmates, or others?
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2. How do you react?
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3. Does your child ever hurt himself on purpose? Yes / No
4. If yes, how?
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5. Can your child stand up for himself when attacked by another? Yes / No

Relationships With Others

1. Describe your child's relationships with you and other family members:
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2. Does your child have a strong preference for one parent? Yes / No
3. Which one? ___________________________________________________
4. Does your child have a strong preference for a particular sibling? Yes / No
5. Which one? ___________________________________________________
6. How does your child react to extended family members, family friends, and strangers?
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7. Is your child friendly to everyone, including all strangers? Yes / No

Other information

Use this space to jot down any other information you think is relevant:
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Adapted from BabyCenter LLC, 2006