Pediatricadvanced_ABA

Child’s First Name*

Child’s Last Name*

Date of Birth*

Date

ABA Screening Questions
(This form is intended to be completed by the child’s parents or primary caregivers)

The following questions have been adapted from the Verbal Behavior Assessment created by Mary Lynch Barbera.

Does your child ever use any words?

YESNO

If yes, please describe the amount of words and give examples of what they say:

If no, does your child babble?

YESNO

If yes, please list sounds you have heard:

Can your child ask for things they want with words? Cookie, juice, ball, push me?

YESNO

If yes, please list the items/activities your child requests with words:

If no, how does your child let you know what they wants?

Can your child label things in a book or on flashcards?

YESNO

If so, please estimate the number of things your child can label and give up to 20 examples:

Does your child label things in the natural environment to get your attention to look at something?

YESNO

Can your child imitate words you say? For example if you say “say ball” will they say “ball”?

YESNO

Will they imitate phrases? If you say “I love you” will they repeat “I love you”?

YESNO

Does your child say things they have memorized from movies or things they have heard you say in the past?

YESNO

If yes, please describe:

Can your child fill in the blanks to songs? For example if you sing “Twinkle, Twinkle Little _____,” will your child say “star”?; and if you sing “E, I, E, I ___” will your child fill in “O”?

YESNO

If yes please list songs that your child fills in words or phrases to

Will your child fill in the blanks to fun and/or functional phrases such as filling in “Pooh” when they hear “Winnie the ____”?; and will they answer “bed” when they hear “You sleep in a ______”?

YESNO

Will your child answer WH questions (with no picture or visual clue)? For example if you say “What flies in the sky?” will your child answer “bird” or “plane”?; and will they name at least three animals or colors if you ask them to?

YESNO

Does your child answer questions about their day? For example “What did you eat for lunch today?”

YESNO

Does your child respond to their name when you call it?

If you tell your child to get their shoes or pick up their cup, do they follow your direction without gestures?

If you tell your child to clap their hands or stand up will they do it without gestures?

Will your child touch their body parts if you say “Touch. Where is your nose” or “Touch head”?

YESNO

If yes, please list the body parts they will touch without any gestures from you:

Will your child copy your actions with toys if you tell them “do this”? For example, if you take a car and roll it back and forth and tell your child “Do this” will your child copy you?

YESNO

Will your child copy motor movements such as clap hands or stomp feet if you do it and say “Do this”?

YESNO

Will your child move their fingers (fine motor movements) such as putting their pointer finger out or their thumb up if you do the motion and say “Do this”?

YESNO

Will your child match identical objects to objects, pictures to pictures, and pictures to objects if you tell them to “match”?

YESNOUNSURE

Will your child complete age-appropriate puzzles?

YESNOUNSURE

Is your child currently able to sit at a table or on the floor and do simple tasks with an adult? How long?

YESNO

Is your child potty trained?

YESNO

Does your child engage in self-injurious behavior (e.g. head banging, hand biting, etc.) to communicate wants/needs?

Engaged in aggressive behavior (e.g. hits, pinches, bites others, etc.) to communicate wants/needs?

Does your child engage in destructive behavior (e.g hits/throws objects, tips furniture, etc.) to communicate wants/needs?

Does your child engage in repetitive or perseverative behavior(s) (e.g. hand flapping, body tensing, etc.)?

Does your child display difficulty responding to a change in routine?

Does your child run away from caregivers in the community?

Does your child recognize dangerous situations (running into the street, falling off of the couch, down the stairs)

Does your child show difficulty separating from parents/caregivers?

Please list any dietary restrictions including food allergies as well as any feeding and/or nutritional concerns you may have.

List your child’s favorite(s)- toys, activities, foods, characters, etc.

Our goal is to provide the most therapeutic relationship possible. Do you have religious or spiritual requirements that you would like for us to know about? If yes, how can we show respect for your religious or spiritual beliefs?

Do you have cultural or family customs that you would like for us to know about? If yes, how can we support you?

Children sometimes act or appear younger than their chronological age. What age do you think best describes your child and why?

Self-Help: (Check yes/no)

	YES	NO
Put on shirt independently
Button independently
Zips independently
Ties shoes
Snaps independently
Dress self independently
Reaching for objects
Finger Feeding
Using Knife for cutting
Eating with spoon
Drawing a circle
Cutting with scissors
Bathing independently
Combing hair
Toilet trained Bowel
Bladder
Toileting independently

Does your child have difficulty learning new motor skills compared to other children his/her age?? Do you have any examples?

How well does your child do the following? (Check yes/no) Explain if needed.

	YES	NO
Wake up during the night:
Difficulty falling asleep:
Does your child have a difficult time to wake up in the morning:
Sleep in own bed:
Take naps during the day:
Picky eater:
Avoid certain textures:
Gags at/on foods or utensils:
Avoids food that requires lots of chew:
Independent with toileting:
Following toilet training routine:
Difficulty playing alone:
Difficulty with pretend play:
Difficulty using playground equipment:
Does your child avoid certain types of toys (i.e. textured toys):
Difficulty playing with other children:
Does your child avoid any messy play (i.e. sand, paint, glue, etc):

Describe your child’s bedtime routine

Explain more of your child's eating habits:

Explain more of your child's toileting:

Duration of play:

1-2 min5-10 minmore

If your child has difficulty playing with other children, explain:

How does your child behave or act when engaging in a tantrum (list all behaviors):

Does your child exhibit tantrums:

YESNO

Frequency:_______times/day:

Frequency:_______times/week:

What triggers the tantrums?

Duration of tantrum:

What strategies do you use to calm your child during a tantrum?

What do you do that works the best to obtain cooperation from your child?

Language Information

Manding

Tacting

Echoic

Intraverbals

Receptive

Imitation

Visual Skill

Behavioral Concerns

DEVELOPMENTAL HISTORY

Daily Routines:

Behavior