EI Program Intake Questionnaire – 5 Years Old

Does your child answer different types of questions? *

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

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

Does your child share information about an event or experience (e.g. describes what happened at a birthday party)? *

Is your child's speech understandable to most listeners? *

Does your child name items in a category? *

Does your child stutter (repeat parts of words or whole words) when he/she talks? *

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

Can your child copy shapes or letters 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 color within the lines of a rectangle? *

Can your child fasten buttons? *

Can your child walk on a line without adult support? *

Can your child walk up a flight of stairs without using the railing or having adult support? *

Can your child walk backwards? *

Can your child run at least 50 feet? *

Can your child catch a ball when gently thrown to them? *

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

Can your child kick a ball at least 10 feet? *

Can your child jump down from a 2nd or 3rd step, over a 6-8 inch obstacle, and forward at least 3 feet? *

Can your child hop on one foot? *

Is your child able to play cooperatively with other children of his/her same age? *

Does your child sit, listen, or play independently for at least 5 minutes? *

Does your child state his/her first and last name? *

Can your child recognize and name at least 5 colors? *

Can your child recognize his/her own name in print? *

Does your child count 10 objects? *

Is your child able to recognize and name a circle, square, and triangle? *

Is your child able to draw a person with a face, body, arms, and legs? *

Is your child able to follow a 3-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 sounds 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 texture, not taste. *

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

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