CBCL/1½-5 and LDS - Aseba

LANGUAGE DEVELOPMENT SURVEY FOR AGES 18-35 MONTHSFor office use onlyID #The Language Development Survey assesses children’s word combinations and vocabulary. By carefully completingthe Language Development Survey, you can help us obtain an accurate picture of your child’s developinglanguage. Please print your answers. Be sure to answer all items.I. Was your child born earlier than the usual 9 months after conception?G No G YesChow many weeks early? ________weeks early.II.How much did your child weigh at birth? ________ pounds ________ounces; or ________ grams.III.IV.How many ear infections did your child have before age 24 months?G 0-2 G 3-5 G 6-8 G 9 or moreIs any language beside English spoken in your home?G No G Yes—please list the languages: ___________________ ______________________________________ ___________________SampleV. Has anyone in your family been slow in learning to talk?G No G Yes—please list their relationships to your child; for example, brother, father:________________________________________________________________________VI.Are you worried about your child’s language development?G No G Yes—why? _____________________________________________________________________________________________________________________VII.Does your child spontaneously say words in any language? (not just imitates or understands words)?G No G Yes—if yes, please complete item VIII and page 4.VIII. Does your child combine 2 or more words into phrases? For example: “more cookie,” “car bye-bye.”G No G Yes—please print 5 of your child=s longest and best phrases or sentences.For each phrase that is not in English, print the name of the language.1. _______________________________________________________________2. _______________________________________________________________3. _______________________________________________________________4. _______________________________________________________________5. _______________________________________________________________Be sure you have answered all items. Then see other side.PAGE 3

Please circle each word that your child says SPONTANEOUSLY (not just imitates or understands). If your child saysnon-English versions of words on the list, circle the English word and write the first letter of the language (e.g., S forSpanish). Please include words even if they are not pronounced clearly or are in Ababy talk@ (for example: Ababa@ forbottle).FOODS1. apple2. banana3. bread4. butter5. cake6. candy7. cereal8. cheese9. coffee10. cookie11. crackers12. drink13. egg14. food15. grapes16. gum17. hamburger18. hotdog19. ice cream20. juice21. meat22. milk23. orange24. pizza25. pretzel26. raisins27. soda28. soup29. spaghetti30. tea31. toast32. waterTOYS33. ball34. balloon35. blocks36. book37. crayons38. doll39. picture40. present41. slide42. swing43. teddy bearOUTDOORS44. flower45. house46. moon47. rain48. sidewalk49. sky50. snow51. star52. street53. sun54. treeANIMALS55. bear56. bee57. bird58. bug59. bunny60. cat61. chicken62. cow63. dog64. duck65. elephant66. fish67. frog68. horse69. monkey70. pig71. puppy72. snake73. tiger74. turkey75. turtleSampleBODY PARTS76. arm77. belly button78. bottom79. chin80. ear81. elbow82. eye83. face84. finger85. foot86. hair87. hand88. knee89. leg90. mouth91. neck92. nose93. teeth94. thumb95. toe96. tummyVEHICLES97. bike98. boat99. bus100. car101. motorcycle102. plane103. stroller104. train105. trolley106. truckACTIONS107. bath108. breakfast109. bring110. catch111. clap112. close113. come114. cough115. cut116. dance117. dinner118. doodoo119. down120. eat121. feed122. finish123. fix124. get125. give126. go127. have128. help129. hit130. hug131. jump132. kick133. kiss134. knock135. look136. love137. lunch138. make139. nap140. open141. outside142. pattycake143. peekaboo144. peepee145. push146. read147. ride148. run149. see150. show151. shut152. sing153. sit154. sleep155. stop156. take157. throw158. tickle159. up160. walk161. want162. washHOUSEHOLD163. bathtub164. bed165. blanket166. bottle167. bowl168. chair169. clock170. crib171. cup172. door173. floor174. fork175. glass176. knife177. light178. mirror179. pillow180. plate181. potty182. radio183. room184. sink185. soap186. spoon187. stairs188. table189. telephone190. towel191. trash192. T.V.193. windowPERSONAL194. brush195. comb196. glasses197. key198. money199. paper200. pen201. pencil202. penny203. pocketbook204. tissue205. tooth brush206. umbrella207. watchPLACES208. church209. home210. hospital211. library212. park213. school214. store215. zooMODIFIERS216. all gone217. all right218. bad219. big220. black221. blue222. broken223. clean224. cold225. dark226. dirty227. dry228. good229. happy230. heavy231. hot232. hungry233. little234. mine235. more236. nice237. pretty238. red239. stinky240. that241. this242. tired243. wet244. white245. yellow246. yuckyCLOTHES247. belt248. boots249. coat250. diaper251. dress252. gloves253. hat254. jacket255. mittens256. pajamas257. pants258. shirt259. shoes260. slippers261. sneakers262. socks263. sweaterOTHER264. any letter265. away266. booboo267. byebye268. excuse me269. here270. hi, hello271. in272. me273. meow274. my275. myself276. nightnight277. no278. off279. on280. out281. please282. Sesame St.283. shut up284. thank you285. there286. under287. welcome288. what289. where290. why291. woofwoof292. yes293. you294. yumyum295. any numberPEOPLE296. aunt297. baby298. boy299. daddy300. doctor301. girl302. grandma303. grandpa304. lady305. man306. mommy307. own name308. pet name309. uncle310. name of TVor storycharacterOther words your child says,including non-English words:________________________________________________________________________________________________________________________PAGE 4