EI Program Intake Questionnaire – 4 Years Old

Does your child answer "where" and "when" questions, such as: "Where do you keep your pillow?" or "What do you wear when it is cold outside?" *

Does your child understand language concepts (big/little, most/more, under)? *

Does your child speak in four to five word sentences? *

Do people other than family members understand some of what your child says? *

Can your child hold a crayon with a basic grasp? *

Can your child copy simple lines and shapes when given a model? *

Can your child stack a few blocks? *

Can your child pick up a raisin or cheerio with the thumb and first finger only? *

Can your child cut using scissors? *

Can your child fasten buttons? *

Can your child walk up at least 4 stairs without support? *

Can your child walk backwards? *

Can your child run without falling? *

Can your child catch a ball when gently tossed to him/her? *

Can your child kick a ball forward 2-3 feet? *

Can your child throw a ball at least 10-12 feet? *

Can your child jump upward/forward and down from a step? *

Does your child sit, listen, or play independently for at least 4 minutes? *

Is your child able to wait for his/her turn most of the time? *

Is your child able to state his/her age? *

Can your child point to 6 colors? *

Can your child count 5 objects? *

Does your child point to a circle, square, and triangle? *

Does your child follow a 2 step direction that is not part of a daily routine? *

Does your child sit and rock self? *

Does your child seem to be constantly moving in some way? *

Does your child overreact to common sound or cover his/her ears a lot? *

Does your child consistently avoid certain food textures, such as crunchy (rice krispies) or smooth (pudding) This question is just for textures not taste. *

Does your child become overly distracted, to the point it is difficult to re-direct him or her? *

Is your child's behavior a concern to you? *

Are there any other concerns that you have for your child? *