Questionnaire to be completed by the parent
Select the letter which most accurately describes your child's performance in each situation.
A. Not Yet	B. Some of the time	C. Most of the time	D. Rarely misses this one

Motor Skills
A	B	C	D	6. Can trace or draw a line with control.
A	B	C	D	7. Cuts with scissors.
A	B	C	D	8. Can help dress himself: coat, socks, shoes.
A	B	C	D	9. Uses a fork properly.
A	B	C	D	10. Can catch a medium-sized ball.
A	B	C	D	11. Is able to skip.
A	B	C	D	12. Is able to hop on one foot.

Language Skills
A	B	C	D	13. Tells full name when asked.
A	B	C	D	14. Recognizes first name by sight.
A	B	C	D	15. Orally identifies letters in name.
A	B	C	D	16. Speaks in sentences.
A	B	C	D	17. Listens with interest, to short story (10 minutes or more).
A	B	C	D	18. Identifies picture likenesses and differences.
A	B	C	D	19. Identifies basic colors: Red, Green, Blue, Orange.
A	B	C	D	20. Identifies Shapes: Circle, Square, Triangle, Rectangle
5	10	15	20	21. Counts by rote to ... select highest number.
0	5	10	20	22. Counts objects ... select highest number.

Language Skills - Part 2	In this section, please select all that apply.
23. Identifies numbers	7	4	10	5	1
	6	9	2	8	3
24. Identifies letters	M	o	A	r	S
	P	b	C	E	h
	g	F	D	i

Listening Skills
Administer this portion of the test orally. Work the sample first, in each section.

A. Using Oral Context - Complete the sentence with an appropriate word.

Child's Sample:

I can tie my

25.	At breakfast I like to eat .
26.	At the zoo we saw .
27.	We like to play outside.

B. Initial Sounds - Select the word which does not begin like the others.

Child's Sample:

top

book

tape

tiger

28.	moon	mice	baby	matches
29.	rag	cow	red	rock
30.	say	seal	some	dog
31.	paper	party	man	pen

C. Rhyming Words - Select the word which rhymes with the others.

Child's Sample:

bad

sad

fad

cow

mad

32.	hark	lark	mark	sick	bark
33.	Roy	toy	joy	boy	jazz
34.	pill	hill	sill	drill	sign
35.	plan	fan	pan	mine	ran

D. Initial Sounds - Tell whether or not the pictures begin with the sound of "S".

Child's Sample:

Yes No

36. Yes No

37. Yes No

38. Yes No

39. Yes No

40. Yes No

Interest - Choose the category which best describes your child's interest level.

A. Shows little interest in books and/or reading.

B. Is interested in books for a few minutes at a time, but not of his own initiative.

C. Shows considerable amount of interest in books, but has short attention span.

D. Desires to be read to frequently for short periods of time.

E. Desires to be read to frequently for 15 minutes or more.