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2 Month Questionnaire
For children 1 month 0 days through 2 months 30 days
Today's date:
03
/
14
/
2025
Baby's information:
Name:
Birthdate:
MM
/
DD
/
YYYY
# of weeks premature:
Gender:
Male
Female
Person filling out questionnaire:
Name:
Relationship to baby:
Parent
Guardian
Grandparent or other relative
Foster parent
Teacher
Child care provider
Other
Specify other:
Address:
Phone:
Email:
Names of people assisting in questionnaire completion:
The following questions are about activities babies may do. You baby may have already done some of the activities described here, and there may be some you baby has not begun doing yet. For each item, please check the button that indicates whether you baby is doing the activity regularly, sometimes, or not yet.
Important points to remember:
1. Try each activity with your baby before marking a response.
2. Make completing this questionnaire a game that is fun for you and your baby.
3. Make sure your baby is rested and fed.
Communication
1. Does your baby sometimes make throaty or gurgling sounds?
Yes
Sometimes
Not yet
2. Does your baby make cooing sounds such as "ooo," "gah," and "aah"?
Yes
Sometimes
Not yet
3. When you speak to your baby, does she make sounds back to you?
Yes
Sometimes
Not yet
4. Does your baby smile when you talk to him?
Yes
Sometimes
Not yet
5. Does your baby chuckle softly?
Yes
Sometimes
Not yet
6. After you have been out of sight, does your baby smile or get excited when she sees you?
Yes
Sometimes
Not yet
Gross Motor
1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?
Yes
Sometimes
Not yet
2. When your baby is on her tummy, does she turn her head to the side?
Yes
Sometimes
Not yet
3. When your baby is on his tummy, does he hold his head up longer than a few seconds?
Yes
Sometimes
Not yet
4. When your baby is on her back, does she kick her legs?
Yes
Sometimes
Not yet
5. While your baby is on his back, does he move his head from side to side?
Yes
Sometimes
Not yet
6. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?
Yes
Sometimes
Not yet
Fine Motor
1. Is your baby's hand usually tightly closed when he is awake?
(If your baby used to do this but no longer does, mark "yes.")
Yes
Sometimes
Not yet
2. Does your baby grasp your finger if you touch the palm of her hand?
Yes
Sometimes
Not yet
3. When you put a toy in his hand, does your baby hold it in his hand briefly?
Yes
Sometimes
Not yet
4. Does your baby touch her face with her hands?
Yes
Sometimes
Not yet
5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?
Yes
Sometimes
Not yet
6. Does your baby grab or scratch at her clothes?
Yes
Sometimes
Not yet
Problem Solving
1. Does your baby look at objects that are 8-10 inches away?
Yes
Sometimes
Not yet
2. When you move around, does your baby follow you with his eyes?
Yes
Sometimes
Not yet
3. When you move a toy slowly from side to side in front of your baby's face (about 10 inches away), does your baby follow the toy with her eyes, sometimes turning her head?
Yes
Sometimes
Not yet
4. When you move a small toy up and down slowly in front of your baby's face (about 10 inches away), does your baby follow the toy with his eyes?
Yes
Sometimes
Not yet
5. When you hold your baby in a sitting position, does she look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?
Yes
Sometimes
Not yet
6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?
Yes
Sometimes
Not yet
Personal-Social
1. Does your baby sometimes try to suck, even when she's not feeding?
Yes
Sometimes
Not yet
2. Does your baby cry when he is hungry, wet, tired, or wants to be held?
Yes
Sometimes
Not yet
3. Does your baby smile at you?
Yes
Sometimes
Not yet
4. When you smile at your baby, does she smile back?
Yes
Sometimes
Not yet
5. Does your baby watch his hands?
Yes
Sometimes
Not yet
6. When your baby sees the breast or bottle, does she seems to know she is about to be fed?
Yes
Sometimes
Not yet
Overall
1. Did your baby pass the newborn hearing screening test?
Yes
No
If no, please explain:
2. Does your baby move both hands and both leg equally well?
Yes
No
If no, please explain:
3. Does either parent have a family history of childhood deafness, hearing impairment, or vision problems?
Yes
No
If yes, please explain:
4. Has your baby had any medical problems?
Yes
No
If yes, please explain:
5. Do you have concerns about your baby's behavior (for example, eating, sleeping)?
Yes
No
If yes, please explain:
6. Does anything about your baby worry you?
Yes
No
If yes, please explain:
OVERALL: NO CONCERN
OVERALL: POTENTIAL CONCERN
COMM
POTENTIAL REF
GROSS
POTENTIAL REF
FINE
POTENTIAL REF
PROB SOLV
POTENTIAL REF
PERS-SOC
POTENTIAL REF
SUBMIT FORM
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