Illini Pediatrics LLC, DBA Ideal Pediatrics

30 month Developmental

Child's full name: * Child's Date of birth * Do you have an appointment? *

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, sometimes, or not yet.

Communication

1. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, "What is this?" does your child correctly name at least one picture? 2(a). With your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions? 2 (b) please select from the following in regards to previous question: 3. When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark "sometimes" if she correctly points to at least three different body parts.) 4. Does your child make sentences that are three or four words long? Example of sentence: 5. Without giving your child help by pointing or using gestures, ask him to "put the book on the table" and "put the shoe under the chair." Does your child carry out both of these directions correctly? 6. When looking at a picture book, does your child tell you what is happening or waht action is taking place in the picture (for example, "barking," "running," "eating," or "crying")? You may ask, "What is the dog (or boy) doing?"

Gross Motor

1. Does your child run fairly well, stopping herself without bumping into things or falling? 2. Does your child walk either up or down at least two steps by himself? He may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.) 3. Without holding onto anything for support, does your child kick a ball by swinging his leg forward? 4. Does your child jump with both feet leaving the floor at the same time? 5. Does your child walk up stairs using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall. 6. Does your child stand on one foot for about 1 second without holding onto anything?

Fine Motor

1. Dose your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars? 2. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction? 3. Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace? 4. After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction? 5. After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle? 6. Does your child turn pages in a book one at a time?

Problem Solving

1. When looking in the mirror, ask, "Where is _______?" (Use your child's name.) Does your child point to her image in the mirror? 2. If your child wants something he cannot reach, does he find a chair or box to stand on to reach it (for example, to get a toy on a counter or to "help" you in the kitchen)? 3. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.) 4. When you point to the figure and ask your child, "What is this?" does your child say a word that means a person or something similar? (Mark "yes" for responses like "snowman," "boy," "man," "girl," "Daddy," "spaceman," and "monkey." Please write your child's response below: Enter your child's response: 5. When you say, "Say, 'seven three,'" does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of number and say, "Say 'eight two'". Your child must repeat just one series of two numbers for you to answer "yes" to this question. 6. After your child draws a "picture," even a simple scribble, does she tell you what she drew? ( You may say, "Tell me about your picture," or ask, "What is this?" to prompt her.)

Personal-Social

1. If you do any of the following gestures, does your child copy at least one of them: open and close your mouth, blink your eyes, pull on your earlobe, pat your cheek? 2. Does your child use a spoon to feed himself with little spilling? 3. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she cannot turn? 4. Does your child put on a coat, jacket, or shirt by himself? 5. After you put on loose-fitting pants around her feet, does your child pull them completely up to her waist? 6. When your child is looking in a mirror and you ask, "Who is in the mirror?" does he say either "me" or his own name?

Overall

1. Do you think your child hears well? If no, explain: 2. Do you think your child talks like other toddlers his age? If no, explain: 3. Can you understand most of what your child says? If no, explain: 4. Can other people understand most of what your child says? If no, explain: 5. Do you think your child walks, runs, and climbs like other toddlers her age? If no, explain: 6. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain: 7. Do you have concerns about your child's vision? If yes, explain: 8. Has your child had any medical problems in the last several months? If yes, explain: 9. Do you have any concerns about your child's behavior? If yes, explain: 10. Does anything about your child worry you? If yes, explain:

What would you like to talk about?

Family Routines Learning to Talk and Communicate Getting Along with Others Getting ready for Pre School Safety Have any of your child?s relatives developed new medical problems since your last visit? If yes, please describe: Do you have concerns about how your child sees? Does your child hold objects close when trying to focus? Do your child?s eyes appear unusual or seem to cross, drift, or be lazy? Do your child?s eyelids droop or does one eyelid tend to close? Have your child?s eyes ever been injured? Do you have concerns about how your child hears? Do you have concerns about how your child speaks? Does your child have a dentist? Does your child's primary water source contain fluoride? Have there been any major changes in your family lately? Does your child live with anyone who uses tobacco or spend time in any place where people smoke? Check off each of the following that are true for your child

Lead Screening

Have siblings or playmates with lead poisoning? Live in or regularly visit a house or day care built before 1950? Reside in or visit a house built before 1978 with chipping paint or remodeling within the last 6 months? **Mouth or eat non-food items (pica)? Play in bare soil or reside in a lead smelting area? Reside with an individual that works with or has hobbies using lead? Receive unusual medicines or folk remedies? Between 12 & 72 months, and has never received a blood lead test? Live in an area of the state at high-risk for lead poisoning? (list published annually)

TB Screening

1. Does the child have any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss or fatigue) or an abnormal chest X-ray? 2. In the last 2 years, has the child lived with or spent time with someone who has been sick with TB? 3. Was the child born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East? 4. Has the child lived or traveled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East for more than one month? 5. Have any member of the child's household come to the United States from another country? 6. Is the child exposed to a person who: 7. Is the child/teen in jail or ever been in jail? 8. does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression? If yes, name of disease or medication: