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4 Month Questionnaire
For children 3 months 0 days through 4 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 chuckle softly?
Yes
Sometimes
Not yet
2. After you have been out of sight, does your baby smile or get excited when he sees you?
Yes
Sometimes
Not yet
3. Does your baby stop crying when she hears a voice other than yours?
Yes
Sometimes
Not yet
4. Does your baby make high-pitched squeals?
Yes
Sometimes
Not yet
5. Does your baby laugh?
Yes
Sometimes
Not yet
6. Does your baby make sounds when looking at toys or people?
Yes
Sometimes
Not yet
Gross Motor
1. While your baby is on his back, does he move his head from side to side?
Yes
Sometimes
Not yet
2. 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
3. When your baby is on his tummy, does he hold his head up so that his chin is about 3 inches from the floor for at least 15 seconds?
Yes
Sometimes
Not yet
4. When your baby is on her tummy, does she hold her head straight up, looking around?
(She can rest on her arms while doing this.)
Yes
Sometimes
Not yet
5. When you hold him in a sitting position, does your baby hold his head steady?
Yes
Sometimes
Not yet
6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?
Yes
Sometimes
Not yet
Fine Motor
1. Does your baby hold his hands open or partly open (rather than in fists, as they were when he was a newborn)?
Yes
Sometimes
Not yet
2. When you put a toy in her hand, does your baby wave it about, at least briefly?
Yes
Sometimes
Not yet
3. Does your baby grab or scratch at his clothes?
Yes
Sometimes
Not yet
4. When you put a toy in her hand, does your baby hold onto it for about 1 minute while looking at it, waving it about, or trying to chew it?
Yes
Sometimes
Not yet
5. Does your baby grab or scratch his fingers on a surface in front of him, either while being held in a sitting position or when he is on his tummy?
Yes
Sometimes
Not yet
6. When you hold your baby in a sitting position, does she reach for a toy on a table close by, even though her hand may not touch it?
Yes
Sometimes
Not yet
Problem Solving
1. 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 his eyes, sometimes turning his head?
Yes
Sometimes
Not yet
2. 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 her eyes?
Yes
Sometimes
Not yet
3. When you hold your baby in a sitting position, does he look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of him?
Yes
Sometimes
Not yet
4. When you put a toy in her hand, does your baby look at it?
Yes
Sometimes
Not yet
5. When you put a toy in his hand, does your baby put the toy in his mouth?
Yes
Sometimes
Not yet
6. When you dangle a toy above your baby while she is lying on her back, does your baby wave her arms toward the toy?
Yes
Sometimes
Not yet
Personal-Social
1. Does your baby watch his hands?
Yes
Sometimes
Not yet
2. When your baby has her hands together, does she play with her fingers?
Yes
Sometimes
Not yet
3. When your baby sees the breast or bottle, does he seem to know he is about to be fed?
Yes
Sometimes
Not yet
4. Does your baby help hold the bottle with both hands at once, or when nursing, does she hold the breast with her free hand?
Yes
Sometimes
Not yet
5. Before you smile or talk to your baby, does he smile when he sees you nearby?
Yes
Sometimes
Not yet
6. When in front of a large mirror, does your baby smile or coo at herself?
Yes
Sometimes
Not yet
Overall
1. Does your baby use both hands and both legs equally well?
Yes
No
If no, please explain:
2. When you help your baby stand, are his feet flat on the surface most of the time?
Yes
No
If no, please explain:
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?
Yes
No
If yes, please explain:
4. Does either parent have a family history of childhood deafness or hearing impairment?
Yes
No
If yes, please explain:
5. Do you have concerns about your baby's vision?
Yes
No
If yes, please explain:
6. Has your baby had any medical problems in the last several months?
Yes
No
If yes, please explain:
7. Do you have any concerns about your baby's behavior?
Yes
No
If yes, please explain:
8. 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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