12 month visit

Please correct the errors described below.

12 Month Questionnaire

11 months 0 days to 12 months 30 days (inclusive)

All babies develop at different rates and in different ways. Please do not worry if your baby 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 baby is progressing.

Possible answers:

  • Yes = your baby does this activity (or has done it and has now progressed, e.g., crawling, but is now walking)
  • Sometimes = your baby is just beginning to do this activity (but does not do it regularly)
  • Not Yet = your baby has not yet started doing this

Please leave blank any activities your baby has not been able to try with you.

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly (yes), sometimes, or not yet.

Important Points to Remember:

Try each activity with your baby before marking a response.

Make completing this questionnaire a game that is fun for you and your baby

Make sure your baby is not tired or hungry.

Please bring this questionnaire with you to your baby’s health and development review.

COMMUNICATION

GROSS MOTOR

FINE MOTOR

* If Fine Motor Item 4 is marked “yes” or “sometimes,” mark Fine Motor Item 2 “yes.”

PROBLEM SOLVING

* If Problem Solving Item 5 is marked “yes” or “sometimes,” mark Problem Solving Item 4 “yes.”

PERSONAL-SOCIAL

OVERALL

Parents and providers may use the space below for additional comments.

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