Social-Emotional Greenspan os pe Questionnaire _ Growth chart C3. ‘A Screening Questionnaire for Infants ana Young Chives Stanley |. Greenspan, M.D. Ghild’s name: Sex: () Male [] Female ‘Completed by: : Relationship to child: Examiner's name: Date of testing: Directions ere Piss Wandin pon sore pus sium Saber thow oien you observe the behavot. Mate only one check matk for ‘ach qin, Complete the quesionnaite ntl you rich the stp pone hae yor il his edge he vin ee tell, 4. Can you easily get your child to look at things without thern being very bright corcolarful? Soe Paso et Sete fae ie way Tas face /to get his ot herattention? 8. Can youeasily get your child’ attention lby approaching him or her, or moving him @PsychCorp cs y:02%01oy roca sss [AL rights reserve, Prete i the United Sates of America, To order, call 1-800-211-8378 008-8 men et continued N oRsH2an24-0 wn 280244)‘8, Canyou help your child calm down? 10. Does your child ook at interesting sights, such as your face ora toy? Lo 11. Does your child look at or tum toward interesting sounds? Stop here if your child is 0-3 months old. 1, Does your child sem happy ox plated when he or he ses oor person as {e9.look or smile make Sounds, or move armsin a way that expressesjoyordeNoht?, 13. Dees your child respond to peopetiking or playing with him or herby making sounds or faes (ea, happy sounds ora curious or annoyed ook? | Stop here i your childs 4-5 months old 14. Does your child reach for or point at things, or make distinct sounds to show you = what he or she wants (9, reach out to be picked up or point ata toy)? 15. Does your child exchange two of more smiles, other looks, sounds, of actions. e.g, reaching, qlving, or taking) with a favorite person? eer eee 16. Does your child show you that he or she understands your ations or gestures by ‘making an appropriate gesture in retutn (e.g, make a funny face back at yous ook at something you point t; stop doing something when you shake your head and use a firm volce to say ‘Not";or smile and do more of something when you nod | — with big smile and say "est? 17. oes your eild ust many consecutive aetions ina biek-and-arth way to show you |whathe ot she wants oF to have fun with you eg, smile reach out for ahug.and, ‘when you hug teke your hat putt on his or her heed and smile proudly OR ake your hand lea you t the retigertot tug on the handle, and, after you open ik, - Point to something he or she kes, such as food a bottle of juice or milk)? Stop here if your child is 10-14 months old. 18 Does your child copy or imitate many of your sounds word, or actions while paying with you (eg if you make funny faces and sounds. does she or he copy them)? L 19, Dees your eid Sore for something he or she wants by locking or gettingyouto ook for i? : L 20, ‘Does your child show you what he or she wants or needs by using afew actionsin ‘row (eg, lead you bythe hand to open a door and then touch ot bang on the doctl? 21, Does your chit use wards or try to use words when people talk with o play with coche? Stop here if your child is 122. Does your child copy or imitate familiar make-believe play (eg, feed or hug a doll? 23. Does your child tell you mhat he or she wants with one or a few words (eg, "Iuice"*Open"or’kiss'? 24, Does your child show you he or she understands your simple verbal wish (e<,"Please show me your toy."? Pecan eeu 25. Does your child play make-believe (e.g, feed a doll play house, or pretend to be a ‘TVor movie character) with you or others? 26. Does your child use words or pictures to tell you what he or she i interested in {eg,"See truck)? 27. Does your child use words with one or more peers? ‘2B. Does your child use words or pictures to show what he or she likes or dislikes {eg,"Wantthat*or"No want"? 23, Does your child play make-believe with one or more peers? 30, _Does your child play make-believe with you or others where te story makes sense {eg.have the bears go visit grandmather and then have aig lunch)? 31. Does your child use phrases or sentences with you toask a question about something he or she wants to do (eg,’Mommy go out?""What you doling outside?"Play?" 32 Can your child explain why he or she wants something or wants to do-something {eg,"Why do you want the juice?*Because fm thirsty? 33, Does your child describe his other felings to explain why he or she fs doing ‘something of wants something (eg, “Because Im happy/sad/excited")? 34. Does your child play make-believe with peers as well as adults where the story makes, sense and bas mary pars toit eg, the children goto school, do wark, have lunch, and meetan elephant onthe way home)? 35. Does your chil have conversations with adults and peers that make sense, with {our or more back-and-forth exchanges about a variety of topics (e., feelings, foods, bedtimes, fiends, or school? Stop here if your child is 31-42 months old. 1] fe one)GREENSPAN SOCIAL-EMOTIONAL GROWTH CHART FOR EXAMINER USE ONLY Total Growth Chart Score Sensory Processing Score Score: Possible Emerging Bie Challenges: Mastery: pea, Highest Stage Mastered Total Growth Chart [| (Scores of Most or All of the time): Sensory Processing Score: Emotional Stages e Ues ynols rior ‘tomatoes nob Soporte “Gans nse cliente enti! | “sonal or gees toeomnuniale m if 20 irs ne wor ca itera or teogs ‘es es nan iat peroell ame Engages in eltinips Enis sig se gation Social-Emotional Growth Chart os ts ew Te Bk Childs Age in Months