PLS.5 Home Questionnaire

PLS.5 Home Questionnaire

Preschool Language Scales Fifth Edition
Dear Parent/Caregiver:

This questionnaire will help us learn about your child's communication skills. The questionnaire includes communication behaviors for children age: birth to 2 1/2 years. There are two parts. The questions in Part 1 ask about who your child spends time with and how he or she spends the time. Questions in Part 2 ask about your child's communication and play behaviors.
Complete the questionnaire. Check ALL behaviors that your child has previously exhibited or currently exhibits.
PART 1
My child has:

The language(s) spoken to my child is/are:*

	Language	Environment	Other
English
Spanish
Other

My child spends most of the day at:*

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Home
Daycare/School
Babysitter
Other

When at home, my child spends time with:*

	Spends Time With	Hours Per Day
Mother
Father
Brothers and Sisters
Another Family Member
Other

When watching television, my child likes to watch:*

Children's Programs (e.g., Sesame Street, Baby Einstein)Cartoons (e.g., Spongebob Squarepants)Movies (e.g., Little Mermaid, Toy Story)Other

When at home, my child usually:*

	Weekday (hours per day)	Weekend (hours per day)
Watches Television
Plays with adults
Plays with other children
Plays independently
Other

When spending time with adults, my child often:*

Goes on errands (grocery shopping, taking brother or sister to sports practice)Plays physical games (peek-a-boo, tag, tossing and catching a ball)Plays learning games (names body parts, names colors, counts, names letters, puts together puzzles)Looks at booksOther

When playing with other children, my child sometimes:*

	My child:	Days
Plays beside other children without sharing their toys
Plays with other children by following what they do or say
Plays with other children by telling them what to do
Plays with other children by sharing toys and talking
My child does not play with other children

When playing, my child:*

Shakes and bangs objects (shakes a rattle, bangs a wooden spoon)Plays simple games with me (peek-a-boo, pat-a-cake)Plays with toys appropriately (rolls ball, stacks blocks, makes stuffed dog walk and bark)uses toys in pretend play (uses a straw as a sword, pretends blocks are cookies)Plays with two or more toys together (stacks two or more blocks, rolls/pushes a car into stacked blocks)Acts out familiar situation (dresses a doll, makes a doll drive a car, pretends to eat and drink from toy plates and cups)Acts out unfamiliar situations (flies a doll to the moon, walks a stuffed animal through the jungle)
My child pays attention to what's happening around him or her. For example, my child:*

Reacts to sounds (startles when a door is slammed, looks up when the doorbell rings)Looks up from what he or she is doing when I call his or her name.Looks at people who are talkingLooks for food that's fallen from his or her high chairLooks toward where I am pointing when I say, "Look at the ___"
My child enjoys attention. For example, my child:*

Smiles when I talk to him or her."talks" when I talk to him or her. (coos, gurgles, says sounds like ma, da, ai-yee)Takes turns talking with me using sounds or wordsInvites me to play with him or her. (deliberately drops a toy from the high chair to be picked up, touches me and runs to pay "catch me", brings me a book or toy)
My child follows directions when I:*

use gestures. (hold out my hands to pick him or her up, wave bye bye)say words paired with gestures (say no no while shaking head, say look while pointing)say words and simple phrases (stop, wait, come here, show me)say one part directions (get your blankie, give me a kiss, eat your cracker)say two part directions (find your shoes and bring them here, get your blankie and lay down, get your spoon and eat your ice cream)
My child tells me how he or she feels and what he or she wants. For example, my child:*

Uses different vocalizations to express himself or herself (has different cries, screams when angry, coos when happy, whimpers when tired)Points to things he or she wants (points to a toy, cracker, bottle)Gestures (lifts arms when he or she wants to be lifted up, shakes his or her head to mean no)Uses physical actions (takes me to the refrigerator, crawls into my lap, puts a toy in my hand)Says specific sounds for things (ba for bottle, ma for mama, uh for pick me up)Says specific words for things (no, bye bye, night night, more)Speaks in phrases (no night night, more cookie, want that)Speaks in sentences (I want it. What's that? I go potty.)
My child says words. For example, my child says:*

Family names (mommy, daddy, grandma, granddaddy, brother or sister's name)animals (pet's name, dog, kitty, bird, fish)food (milk, juice, cookie, apple, snack)toys (ball, dolly, balloon)daily routines (go bye bye, eat, bath, night night)body parts (eye, nose, mouth, hand)clothing (shoe, sock,shirt)

My child's speech is understood by:*

	how often
Household family members
Other family members
Care providers
Familiar people
Unfamiliar people

My child correctly says these sounds (check all that apply):*

bdfhlmnprtvwyzbrchgrshslstrththrtrg (as in girl)k (as in kite)a (as in cat)e (as in pet)i (as in hit)o (as in hot)u (as in cup)j (as in jelly)s (as in site)a (as in cake)e (as in tree)i (as in like)o (as in go)u (as in blue)
Should be Empty:

PLS.5 Home Questionnaire

Complete the questionnaire. Check ALL behaviors that your child has previously exhibited or currently exhibits.

PART 1