Ages and Stages Questionnaire - 12 month English

Ages & Stages
Questionnaires®

12 Month Questionnaire

11 months 0 days through 12 months 30 days

Please provide the following information. Use black or blue ink only and print
legibly when completing this form.

Date ASQ completed:

Baby’s information
Middle
initial:

Baby’s first name:

Baby’s last name:
If baby was born 3
or more weeks
prematurely, # of
weeks premature:

Baby’s date of birth:

Baby’s gender:
Male

Female

Person filling out questionnaire
Middle
initial:

First name:

Last name:
Relationship to baby:

Street address:

Parent

Guardian

Teacher

Grandparent
or other
relative

Foster
parent

Other:

City:

State/
Province:

ZIP/
Postal code:

Country:

Home
telephone
number:

Other
telephone
number:

E-mail address:

Names of people assisting in questionnaire completion:

Program Information
Baby ID #:

Age at administration in months and days:

Program ID #:

If premature, adjusted age in months and days:

Program name:

P101120100

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

Child care
provider

12 Month Questionnaire

11 months 0 days
through 12 months 30 days

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities
described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:
✓ Try each activity with your baby before marking a response.
❑
✓ Make completing this questionnaire a game that is fun for
❑
you and your baby.

Notes:
____________________________________________
____________________________________________

✓ Make sure your baby is rested and fed.
❑

____________________________________________

✓ Please return this questionnaire by _______________.
❑

____________________________________________

COMMUNICATION

YES

SOMETIMES

NOT YET

1. Does your baby make two similar sounds, such as “ba-ba,” “da-da,” or
“ga-ga”? (The sounds do not need to mean anything.)
2. If you ask your baby to, does he play at least one nursery game even if
you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)?
3. Does your baby follow one simple command, such as “Come here,”
“Give it to me,” or “Put it back,” without your using gestures?
4. Does your baby say three words, such as “Mama,” “Dada,” and
“Baba”? (A “word” is a sound or sounds your baby says consistently to
mean someone or something.)
5. When you ask, “Where is the ball (hat, shoe, etc.)?” does your baby
look at the object? (Make sure the object is present. Mark “yes” if she
knows one object.)
6. When your baby wants something, does he tell you by pointing to it?

COMMUNICATION TOTAL

GROSS MOTOR

YES

SOMETIMES

NOT YET

1. While holding onto furniture, does your baby bend down
and pick up a toy from the floor and then return to a
standing position?

2. While holding onto furniture, does your baby lower herself with control
(without falling or flopping down)?
3. Does your baby walk beside furniture while holding on with only one
hand?
page 2 of 6

E101120200

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

12 Month Questionnaire
GROSS MOTOR

(continued)

YES

SOMETIMES

page 3 of 6

NOT YET

4. If you hold both hands just to balance your baby, does he
take several steps without tripping or falling? (If your baby
already walks alone, mark “yes” for this item.)

5. When you hold one hand just to balance your baby, does
she take several steps forward? (If your baby already walks
alone, mark “yes” for this item.)

6. Does your baby stand up in the middle of the floor by himself and take
several steps forward?

GROSS MOTOR TOTAL

FINE MOTOR

YES

SOMETIMES

NOT YET

1. After one or two tries, does your baby pick up a piece
of string with his first finger and thumb? (The string
may be attached to a toy.)
2. Does your baby pick up a crumb or Cheerio with the
tips of her thumb and a finger? She may rest her arm or
hand on the table while doing it.
3. Does your baby put a small toy down, without dropping it, and then
take his hand off the toy?
4. Without resting her arm or hand on the table, does your
baby pick up a crumb or Cheerio with the tips of her
thumb and a finger?

*

5. Does your baby throw a small ball with a forward arm
motion? (If he simply drops the ball, mark “not yet” for
this item.)

6. Does your baby help turn the pages of a book? (You may lift a page for
him to grasp.)

FINE MOTOR TOTAL
*If Fine Motor Item 4 is marked
“yes” or “sometimes,” mark Fine
Motor Item 2 “yes.”

E101120300

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

12 Month Questionnaire
PROBLEM SOLVING

YES

SOMETIMES

page 4 of 6

NOT YET

1. When holding a small toy in each hand, does your baby clap the toys
together (like “Pat-a-cake”)?
2. Does your baby poke at or try to get a crumb or Cheerio that is inside a
clear bottle (such as a plastic soda-pop bottle or baby bottle)?
3. After watching you hide a small toy under a piece of paper or cloth,
does your baby find it? (Be sure the toy is completely hidden.)
4. If you put a small toy into a bowl or box, does your baby copy you by
putting in a toy, although she may not let go of it? (If she already lets
go of the toy into a bowl or box, mark “yes” for this item.)

*

5. Does your baby drop two small toys, one after the
other, into a container like a bowl or box? (You may
show him how to do it.)

6. After you scribble back and forth on paper with a crayon (or a pencil or
pen), does your baby copy you by scribbling? (If she already scribbles
on her own, mark “yes” for this item.)

PROBLEM SOLVING TOTAL
*If Problem Solving Item 5 is marked
“yes” or “sometimes,” mark Problem
Solving Item 4 “yes.”

PERSONAL-SOCIAL

YES

SOMETIMES

NOT YET

1. When you hold out your hand and ask for his toy, does your baby offer
it to you even if he doesn’t let go of it? (If he already lets go of the toy
into your hand, mark “yes” for this item.)
2. When you dress your baby, does she push her arm through a sleeve
once her arm is started in the hole of the sleeve?
3. When you hold out your hand and ask for his toy, does your baby let go
of it into your hand?
4. When you dress your baby, does she lift her foot for her shoe, sock, or
pant leg?
5. Does your baby roll or throw a ball back to you so that you can return it
to him?
6. Does your baby play with a doll or stuffed animal by hugging it?

PERSONAL-SOCIAL TOTAL

E101120400

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

12 Month Questionnaire
OVERALL
Parents and providers may use the space below for additional comments.
1. Does your baby use both hands and both legs equally well? If no, explain:

YES

NO

2. Does your baby play with sounds or seem to make words? If no, explain:

YES

NO

3. When your baby is standing, are her feet flat on the surface most of the time?
If no, explain:

YES

NO

4. Do you have concerns that your baby is too quiet or does not make sounds like
other babies do? If yes, explain:

YES

NO

5. Does either parent have a family history of childhood deafness or hearing
impairment? If yes, explain:

YES

NO

E101120500

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

page 5 of 6

12 Month Questionnaire
OVERALL

(continued)

6. Do you have concerns about your baby’s vision? If yes, explain:

YES

NO

7. Has your baby had any medical problems in the last several months? If yes, explain:

YES

NO

8. Do you have any concerns about your baby’s behavior? If yes, explain:

YES

NO

9. Does anything about your baby worry you? If yes, explain:

YES

NO

E101120600

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

page 6 of 6

12 Month ASQ-3 Information Summary

11 months 0 days through
12 months 30 days

Baby’s name: ______________________________________________________ Date ASQ completed: __________________________________________
Baby’s ID #: ______________________________________________________ Date of birth: ______________________________________________
Was age adjusted for prematurity
when selecting questionnaire?

Administering program/provider:

Yes

No

1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User’s Guide for details, including how to adjust scores if item
responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.
In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.

2.

3.

Area

Cutoff

Communication

15.64

Gross Motor

21.49

Fine Motor

34.50

Problem Solving

27.32

Personal-Social

21.73

Total
Score

0

5

10

15

20

25

30

35

40

45

50

55

60

TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.
1. Uses both hands and both legs equally well?
Comments:

Yes

NO

6. Concerns about vision?
Comments:

YES

No

2. Plays with sounds or seems to make words?
Comments:

Yes

NO

7. Any medical problems?
Comments:

YES

No

3. Feet are flat on the surface most of the time?
Comments:

Yes

NO

8. Concerns about behavior?
Comments:

YES

No

4. Concerns about not making sounds?
Comments:

YES

No

9. Other concerns?
Comments:

YES

No

5. Family history of hearing impairment?
Comments:

YES

No

ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall
responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
If the baby’s total score is in the
If the baby’s total score is in the
If the baby’s total score is in the

area, it is above the cutoff, and the baby’s development appears to be on schedule.
area, it is close to the cutoff. Provide learning activities and monitor.
area, it is below the cutoff. Further assessment with a professional may be needed.

4. FOLLOW-UP ACTION TAKEN: Check all that apply.
______ Provide activities and rescreen in _____ months.

5. OPTIONAL: Transfer item responses
(Y = YES, S = SOMETIMES, N = NOT YET,
X = response missing).

______ Share results with primary health care provider.
______ Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
______ Refer to primary health care provider or other community agency (specify
reason): __________________________________________________________.
______ Refer to early intervention/early childhood special education.
______ No further action taken at this time

1
Communication
Gross Motor
Fine Motor
Problem Solving
Personal-Social

______ Other (specify): ____________________________________________________

P101120700

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

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