This information is optional. It is not stored and used only for inclusion on the assessment result printout.
Child's First Name:
Does your child:
Have difficulty playing independently?
Not like it when others join in or change things in their play?
Engage in limited or rigid play (e.g. will only play with Thomas the Tank engine, lines items up)?
Have difficulty engaging in pretend play (e.g. putting teddy to bed, having a tea party)?
Have difficulty playing with or alongside other children, or fails to notice peers in their play space?
Tend to flit from one activity to the next without really engaging in or focusing on anything?
Have difficulty responding to their name by looking when called?
Have difficulty concentrating by looking and listening and needs a lot of prompting to remain engaged in an activity?
Have difficulty attending to an adult's choice or method of activity?
Have difficulty listening to an age-appropriate book being read?
Show difficulty copying or imitating gestures or actions (e.g. clapping, waving, jumping)?
Show difficulty understanding the daily routine (e.g. after dinner, it is bath time, then bed time)
Tend not to bring your attention to things or share information or interests with you (e.g. pointing to a dog in the park and looking to make sure you saw the dog they are pointing to)?
Vocalise very little and/or tend to use only a few types of sounds (e.g. may use a humming sound only or mostly just say "uh uh uh")?
Have difficulty using gestures (e.g. pointing, waving), sounds and facial expressions to get their needs and wants (e.g. pointing to the biscuit and saying "uh uh uh")?
Have difficulty understanding or responding appropriately to non-verbal information (e.g. facial expressions-smile, frown, tone of voice- angry, soft, happy, gestures-waving, pointing)?
Have difficulty understanding single words or objects (e.g. When you say "Where's the ball", does not look at or reach for the ball)?
Have difficulty understanding early concepts (e.g. big vs little, fast vs slow)?
Have difficulty finding familiar body parts when named (e.g. "Where is your nose /mouth")?
Have difficulty understanding action words (e.g. "Who is running" in a picture or "make the teddy jump" when playing with teddy)?
Have difficulty understanding what you say and following simple instructions?
Take longer than expected to follow an instruction or often requires repetition?
Have difficulty following longer instructions (i.e. may only do the first or last thing that has been said)?
Have difficulty understanding simple "what", "where", "who" questions?
Often talk about what they want to talk about, instead of listening and responding to what you have said?
Show little (or brief) interest in sitting down and looking at pictures in a book with you?
Have difficulty listening to a story for long and/or attends for only a very short time?
Seem more interested in turning the pages of a book rather than listening to the story?
Appear unable to point to a picture within a book when requested (e.g. "Where's the dog")?
Seem unable to answer questions about what is happening in the story (e.g. "What is the boy doing"? "Where is the cat"? "Why is she sad")?
Have difficulty using single words (e.g. "milk" or "more")?
Have difficulty naming items (e.g. calls all 4 legged animals dogs, calls a table a chair)?
Use vocabulary limited in terms of amount and types of words used (e.g. uses only naming words and does not have many action or descriptive words, has vocabulary only around a certain topic of interest)?
Have difficulty using descriptive words like "hot, cold, big, little, fast, slow"?
Have difficulty with greetings (e.g. "hello/goodbye") and social words (e.g. "please/thank you")?
Make errors with grammatical endings on words (e.g. indicating past and present tense - kicking vs kicked; plural 's' - cat vs cats)?
Leave out small words from sentences (e.g. words like it, is, a, the) causing language to sound immature?
Have difficulty using linking words such as "and", "because" or "but" to join phrases together?
Put words in the wrong order (e.g. "The ball is garden in it")?
Have difficulty forming questions, so that they make statements instead or do not know whether to use "what vs. who vs. why" (e.g. may say "what that" when pointing to a picture of a man")?
Have difficulty linking 2-3 words into short phrases (e.g. "mummy car", "doggy eat")?
Find it hard to combine 5-6 words together (e.g. "Look at man in car daddy")?
Have difficulty producing longer sentences that express more complex ideas (e.g. "The dog is jumping over the fence to get to the bone because he's hungry")?
Have difficulty talking about something in the past (e.g. what they had for breakfast or what they did at kindy)?
Have difficulty re-telling a simple story?
Dribble more than expected for their age?
Have their mouth open at rest or breathe through their mouth?
Have difficulty blowing through or sucking from a straw?
Have difficulty chewing, moving food around the mouth and/or swallowing (e.g. gags or coughs when eating)?
Have difficulty eating lumpy textured foods (e.g. chopped vegetables, stews)?
Seem to have difficulty forming speech sounds and words (e.g. does not use any consonants in speech, looks like they are trying to attempt to make sounds or words with mouth, but it is not coming out or it is hard to understand)?
Have difficulty being understood by others?
Have difficulty getting their message understood so that they often get frustrated?
Have speech which is immature or "babyish" compared to their peers?
Have speech which contains sound 'substitutions' that other children their age don't make (e.g. "c" sounds replaced by "t" sounds- "car" becomes "tar"), ?
Have a voice that often sounds hoarse/harsh/breathy or monotonous (i.e. robot-like)?
Have a voice that often sounds 'nasal' (i.e. like the child has a blocked nose)?
Use a very loud voice or shout often which affects the sound of voice?
Often repeat first sounds in words, part of words or phrases when talking (e.g. "C...C...can I have a biscuit" or "Gi...Gi...give me the ball") or lengthen words (e.g. "Loooooook at the cat")?
Have difficulty getting the word or sentence out so that they get frustrated?