Basic Communication Questionnaire Fill Out the Basic Communication Questionnaire Basic Communication Questionnaire Date* MM slash DD slash YYYY Parent's Name First Last Child's First Name* First Child's Last Name* Last Date of Birth* MM slash DD slash YYYY Gender Home Phone*Email* What does your child typically do at home? (check all that apply) Plays with adults Plays with siblings Plays alone Watches TV or tablet Other(please comment below) Additional Comments What does your child like to do with adults? (check all that apply) Plays with toys/games Plays outside Runs errands Looks at books Plays physical games Other (please comment below) Additional Comments How does your child play with other children? (check all that apply) Plays beside them without interacting Interacts with them by talking and sharing toys Tells other children what to do Follows along with what other children tell them to do Does not play with other children Other (please comment below) Additional Comments How does your child play with toys? (check all that apply) Shakes or bangs them Plays appropriately (stacking/assembling blocks, rolling ball, holding baby doll, etc.) Combines toys in play (e.g., using a stick to bang on a pot) Uses toys symbolically (e.g., holding up a spoon as if to talk on the phone) Acts out familiar routines (e.g., dressing a doll, pretending to eat) Acts out imaginary situations Other (please comment below) Additional Comments How does your child interact with you? (check all that apply) Smiles/laughs when I talk to them Makes sounds back and forth with me Gestures for me to do things Talks back and forth with me with words Other (please comment below) Additional Comments What types of directions does your child follow? (check all that apply) Follows familiar 1-step directions (e.g., go get your shoes) Follows familiar 2-step directions (e.g., get your shoes and then go to the door) Follows novel directions (e.g., put the ball on your head, go outside and pick a flower) Does not follow directions Other (please comment below) Additional Comments What types of words does your child use? (check all that apply) Words to label items or people (e.g., ball, dog, mom) Words to request (e.g., want, more, come) Words to protest (e.g., no, stop) Words for social purposes (e.g., hi, bye, please) Words to describe actions (e.g., run, kick, eat) Words to describe objects (e.g., colors, size, shape) Does not use words Other (please comment below) Additional Comments What kinds of sentences can your child make? Imitates words that an adult models only Uses only 1 word at a time Uses 2 words at a time (e.g., hi mommy) Uses 3 words at a time (e.g., mommy go work) Uses 4 or more words at a time Other (please comment below) Additional Comments How does your child express their feelings? (check all that apply) With body language/actions (e.g., cries when upset, smiles/laughs when happy) Uses words like I’m happy/sad/mad Describes how they feel and why (e.g., I’m mad because he took my toy) I can’t tell how my child is feeling Other (please comment below) Additional Comments How does your child relate what has happened? (check all that apply) Gestures to indicate what has happened (e.g., showing a broken toy, points to the problem) Uses a combination of gestures and sounds/jargon Uses a word or two (e.g., Johnny fall) Uses a full sentence Is not able to tell me what has happened Other (please comment below) Additional Comments Can others understand what your child says? Yes, strangers can understand them Our family understands them, but unfamiliar listeners have a hard time Some members of our family understand them, but some do not We cannot understand what they say Other (please comment below) Additional Comments Does your child have any behavioral challenges? (check all that apply) Easily frustrated/upset Has a hard time separating from me Cannot play by themself Shows aggression (towards themself or others) Short attention span Hesitant to try new activities Struggles to transition between activities Demonstrates decreased safety awareness Other (please comment below) Additional Comments Does your child have any significant medical history? (check all that apply) Adenoidectomy Tonsillectomy Thumb sucking/finger sucking Breathing difficulties Ear infections Ear tubes Head injury Vision problems Seizures Other (please comment below) Additional Comments CAPTCHA Δ
