48 Month Questionnaire

Ages & Stages Questionnaires: A Parent-Completed, Child-Monitoring System

Second Edition
By Diane Bricker and Jane Squires
with assistance from Linda Mounts, LaWanda Potter, Robert Nickel, Elizabeth Twombly, and Jane Farrell
Copyright © 1999 by Paul H. Brookes Publishing Co.

On the following pages are questions about activities children do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please check the box that tells whether your child is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:

Be sure to try each activity with your child before checking a box.
Try to make completing this questionnaire a game that is fun for you and your child.
Make sure your child is rested, fed, and ready to play.
Please return this questionnaire by ____.
If you have any questions or concerns about your child or about this questionnaire, please call: (773) 348-8300
Look forward to filling out another questionnaire in ____ months.

Complete By Date:

48 Month - 4 Year Questionnaire

Please provide the following information.

Child's name:

Child's date of birth:

Today's date:

Person filling out this questionnaire:

What is your relationship to the child?

Your telephone:

Your mailing address:

City:

State:

Zip code:

List people assisting in questionnaire completion:

Administering program or provider:

COMMUNICATION

Be sure to try each activity with your child.

1. Does your child name at least three items from a common category? For example, if you say to your child, ''Tell me some things that you can eat," does your child answer with something like, "Cookies, eggs, and cereal"? Or if you say, ''Tell me the names of some animals," does your child answer with something like, "Cow, dog, and elephant"?

Yes

Sometimes

Not Yet

Score:

2. Does your child answer the following questions:

"What do you do when you are hungry?" (Acceptable answers include: "Get food," "Eat," "Ask for something to eat," and "Have a snack.")

Score:

Please write your child's response:

"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:

Mark "sometimes" if your child answers only one question.

Yes

Sometimes

Not Yet

3. Does your child tell you at least two things about common objects? For example, if you say to your child, ''Tell me about your ball," does he say something like, "It's round. I throw it. It's big"?

Yes

Sometimes

Not Yet

Score:

4. Does your child use endings of words, such as "s," "ed," and "ing"? For example, does your child say things like, "I see two cats," "I am playing," or "I kicked the ball"?

Yes

Sometimes

Not Yet

Score:

5. Without giving help by pointing or repeating, does your child follow three directions that are unrelated to one another? For example, you may ask your child to "Clap your hands, walk to the door, and sit down."

Yes

Sometimes

Not Yet

Score:

6. 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?"

Yes

Sometimes

Not Yet

Score:

COMMUNICATION TOTAL:

GROSS MOTOR

Be sure to try each activity with your child.

1. 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.

Yes

Sometimes

Not Yet

Score:

2. Does your child climb the rungs of a ladder of a playground slide and slide down without help?

Yes

Sometimes

Not Yet

Score:

3. 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 her arm to shoulder height and throw the ball forward. (Dropping the ball, letting the ball go, or throwing the ball underhand should be scored as "not yet.")

Yes

Sometimes

Not Yet

Score:

4. Does your child hop up and down on either the right or left foot at least one time without losing his balance or falling?

Yes

Sometimes

Not Yet

Score:

5. Does your child jump forward a distance of 20 inches from a standing position, starting with her feet together?

Yes

Sometimes

Not Yet

Score:

6. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing his balance and pulling his foot down? You may give your child two or three tries before you mark the question.

Yes

Sometimes

Not Yet

Score:

GROSS MOTOR TOTAL:

FINE MOTOR

Be sure to try each activity with your child.

1. Does your child put together a six-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)

Yes

Sometimes

Not Yet

Score:

2. Using child-safe scissors, does your child cut a 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.)

Yes

Sometimes

Not Yet

Score:

3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil or crayon, without tracing? Your child's drawings should look similar to the design of the shapes below, but they may be different in size. Shapes: L + | O

Yes

Sometimes

Not Yet

Score:

4. Does your child unbutton one or more buttons? Your child may use his own clothing or a doll's clothing.

Yes

Sometimes

Not Yet

Score:

5. Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?

Yes

Sometimes

Not Yet

Score:

6. Does your child color mostly within the lines in a coloring book? Your child should not go more than 1/4 inch outside the lines on most of the picture.

Yes

Sometimes

Not Yet

Score:

FINE MOTOR TOTAL:

PROBLEM SOLVING

Be sure to try each activity with your child.

1. When you say, "Say five eight three," does your child repeat just these three numbers in the correct order? Do not repeat these numbers. If necessary, try another series of numbers and say, "Say six nine two." Your child must repeat just one series of three numbers to answer "yes" to this question.

Yes

Sometimes

Not Yet

Score:

2. 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. Shapes: o O O

Yes

Sometimes

Not Yet

Score:

3. Without giving help by pointing, does your child follow three different directions using the words "under," "between," and "middle"? For example, ask your child to put a book "under the couch." Then ask her to put the ball "between the chairs" and the shoe "in the middle of the table."

Yes

Sometimes

Not Yet

Score:

4. When shown an object and asked, "What color is this?" does your child name five different colors like red, blue, yellow, orange, black, white, or pink? Answer "yes" only if your child answers the question correctly using five colors.

Yes

Sometimes

Not Yet

Score:

5. 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 mommy, daddy, brother or sister, or an imaginary animal or figure.

Yes

Sometimes

Not Yet

Score:

6. If you place five objects in front of your child, can he count them saying, "One, two, three, four, five," in order? Ask this question without providing help by pointing, gesturing, or naming.

Yes

Sometimes

Not Yet

Score:

PROBLEM SOLVING TOTAL:

PERSONAL-SOCIAL

Be sure to try each activity with your child.

1. Does your child serve herself, taking food from one container to another using utensils? For example, can your child use a large spoon to scoop applesauce from a jar into a bowl?

Yes

Sometimes

Not Yet

Score:

2. Does your child tell you at least four of the following:

a. First name

b. Age

c. City she lives in

d. Last name

e. Boy or girl

f. Telephone number

Score:

Please select the items your child knows.

Yes

Sometimes

Not Yet

3. Does your child wash his hands and face using soap and dry off with a towel without help?

Yes

Sometimes

Not Yet

Score:

4. Does your child tell you the names of two or more playmates, not including brothers and sisters? Ask this question without providing help by suggesting names of playmates or friends.

Yes

Sometimes

Not Yet

Score:

5. Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all her teeth without help? You may still need to check and rebrush your child's teeth.

Yes

Sometimes

Not Yet

Score:

6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?

Yes

Sometimes

Not Yet

Score:

PERSONAL-SOCIAL TOTAL:

OVERALL

Parents and providers may use the space at the bottom of this page for additional comments.

1. Do you think your child hears well?

Yes

If no, explain:

2. Do you think your child talks like other children her age?

Yes

If no, explain:

3. Can you understand most of what your child says?

Yes

If no, explain:

4. Do you think your child walks, runs, and climbs like other children his age?

Yes

If no, explain:

5. Does either parent have a family history of childhood deafness or hearing impairment?

Yes

If yes, explain:

6. Do you have any concerns about your child's vision?

Yes

If yes, explain:

7. Has your child had any medical problems in the last several months?

Yes

If yes, explain:

8. Does anything about your child worry you?

Yes

If yes, explain:

Additional comments:

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