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pdfOMB CONTROL NUMBER: 0704-XXXX
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE
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estimated to average 15 minutes per response, including the time for reviewing
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comply with a collection of information if it does not display a currently valid OMB
control number.
ASQ-3 2-Month Version
Please provide the following information.
Date ASQ Completed (MM/DD/YYYY):
________________________________________________
Baby's date of birth: ________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
Page 1 of 139
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 select the response 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.
• Make sure your baby is rested and fed.
COMMUNICATION
YES
SOMETIMES
NOT YET
1. Does your baby
sometimes make
throaty or gurgling
sounds?
o
o
o
2. Does your baby
make cooing sounds
such as "ooo," "gah,"
and "aah"?
o
o
o
3. When you speak
to your baby, does
she make sounds
back to you?
o
o
o
4. Does your baby
smile when you talk
to him?
o
o
o
o
o
o
o
o
o
5. Does your baby
chuckle softly?
6. After you have
been out of sight,
does your baby smile
or get excited when
she sees you?
GROSS MOTOR
YES
1. While your baby is
on his back, does he
wave his arms and
legs, wiggle, and
squirm?
o
SOMETIMES
o
NOT YET
o
Page 2 of 139
2. When your baby is
on her tummy, does
she turn her head to
the side?
o
o
o
o
o
o
4. When your baby is
on her back, does
she kick her legs?
o
o
o
5. While your baby is
on his back, does he
move his head from
side to side?
o
o
o
o
o
o
3. When your baby is
on his tummy, does
he hold his head up
longer than a few
seconds?
6. After holding her
head up while on her
tummy, does your
baby lay her head
back down on the
floor, rather than let it
drop or fall forward?
FINE MOTOR
YES
1. Is your baby's
hand usually tightly
closed when he is
awake? (If your baby
used to do this but no
longer does, mark
"YES")
SOMETIMES
NOT YET
o
o
o
2. Does your baby
grasp your finger if
you touch the palm of
her hand?
o
o
o
3. When you put a
toy in his hand, does
your baby hold it in
his hand briefly?
o
o
o
o
o
o
4. Does your baby
touch her face with
Page 3 of 139
her hands?
5. Does your baby
hold his hands open
or partly open when
he is awake (rather
than in fists, as they
were when he was a
newborn)?
6. Does your baby
grab or scratch at her
clothes?
o
o
o
o
o
o
PROBLEM SOLVING
YES
SOMETIMES
NOT YET
1. Does your baby
look at objects that
are 8-10 inches
away?
o
o
o
2. When you move
around, does your
baby follow you with
his eyes?
o
o
o
o
o
o
o
o
o
o
o
o
3. When you move a
toy slowly from side
to side in front of your
baby's face (about 10
inches away), does
your baby follow the
toy with her eyes,
sometimes turning
her head?
4. When you move a
small toy up and
down slowly in front
of your baby's face
(about 10 inches
away), does your
baby follow the toy
with his eyes?
5. When you hold
your baby in a sitting
position, does she
look at a toy (about
the size of a cup or
Page 4 of 139
rattle) that you place
on the table or floor
in front of her?
6. When you dangle
a toy above your
baby while he is lying
on his back, does he
wave his arms
toward the toy?
o
o
o
PERSONAL-SOCIAL
YES
SOMETIMES
NOT YET
1. Does your baby
sometimes try to
suck, even when
she's not feeding?
o
o
o
2. Does your baby
cry when he is
hungry, wet, tired, or
wants to be held?
o
o
o
o
o
o
o
o
o
5. Does your baby
watch his hands?
o
o
o
6. When your baby
sees the breast or
bottle, does she
seem to know she is
about to be fed?
o
o
o
3. Does your baby
smile at you?
4. When you smile at
your baby, does she
smile back?
OVERALL
1. Did your baby pass the newborn hearing screening test? If no, explain.
o Yes
o No ________________________________________________
2. Does your baby move both hands and both legs equally well? If no, explain.
o Yes
Page 5 of 139
o No ________________________________________________
3. Does either parent have a family history of childhood deafness, hearing impairment, or vision
problems? If yes, explain.
o Yes ________________________________________________
o No
4. Has your baby had any medical problems? If yes, explain.
o Yes ________________________________________________
o No
5. Do you have concerns about your baby's behavior (for example, eating, sleeping)? If yes,
explain.
o Yes ________________________________________________
o No
6. Does anything about your baby worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Page 6 of 139
▢
▢
Refer for 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.
Other (specify): ________________________________________________
Page 7 of 139
ASQ-3 4-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYY):
________________________________________________
Baby's date of birth (MM/DD/YYYY):
________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
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 click 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.
• Make sure your baby is rested and fed.
COMMUNICATION
YES
1. Does your baby
chuckle softly?
2. After you have
been out of sight,
does your baby smile
or get excited when
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 8 of 139
he sees you?
3. Does your baby
stop crying when she
hears a voice other
than yours?
o
o
o
4. Does your baby
make high-pitched
squeals?
o
o
o
o
o
o
o
o
o
5. Does your baby
laugh?
6. Does your baby
make sounds when
looking at toys or
people?
GROSS MOTOR
YES
1. While your baby is
on his back, does he
move his head from
side to side?
2. After holding her
head up while on her
tummy, does your
baby lay her head
back down on the
floor, rather than let it
drop or fall forward?
3. When your baby is
on his tummy, does
he hold his head up
so that his chin is
about 3 inches from
the floor for at least
15 seconds?
4. When your baby is
on her tummy, does
she hold her head
straight up, looking
around? (She can
rest her arms while
doing this.)
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 9 of 139
5. When you hold
him in a sitting
position, does your
baby hold his head
steady?
6. While your baby is
on her back, does
your baby bring her
hands together over
her chest, touching
her fingers?
o
o
o
o
o
o
FINE MOTOR
YES
1. Does your baby
hold his hands open
or partly open (rather
than in fists, as they
were when he was a
newborn)?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
5. Does your baby
grab or scratch his
fingers on a surface
in front of him, either
while being held in a
sitting position or
when he is on his
tummy?
o
o
o
6. When you hold
your baby in a sitting
o
o
o
2. When you put a
toy in her hand, does
your baby wave it
about, at least
briefly?
3. Does your baby
grab or scratch at his
clothes?
4. When you put a
toy in her hand, does
your baby hold onto it
for about 1 minute
while looking at it,
waving it about, or
trying to chew it?
Page 10 of 139
position, does she
reach for a toy on a
table close by, even
though her hand may
not touch it?
PROBLEM SOLVING
YES
1. When you move a
toy slowly from side
to side in front of your
baby's face (about 10
inches away), does
your baby follow the
toy with his eyes,
sometimes turning
his head?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
4. When you put a
toy in her hand, does
your baby look at it?
o
o
o
5. When you put a
toy in his hand, does
your baby put the toy
in his mouth?
o
o
o
o
o
o
2. When you move a
small toy up and
down slowly in front
of your baby's face
(about 10 inches
away), does your
baby follow the toy
with her eyes?
3. When you hold
your baby in a sitting
position, does he
look at a toy (about
the size of a cup or
rattle) that you place
on the table or floor
in front of him?
6. When you dangle
a toy above your
baby while she is
lying on her back,
does your baby wave
Page 11 of 139
her arms toward the
toy?
PERSONAL-SOCIAL
YES
1. Does your baby
watch his hands?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
5. Before you smile
or talk to your baby,
does he smile when
he sees you nearby?
o
o
o
6. When in front of a
large mirror, does
your baby smile or
coo at herself?
o
o
o
2. When your baby
has her hands
together, does she
play with her fingers?
3. When your baby
sees the breast or
bottle, does he seem
to know he is about
to be fed?
4. Does your baby
help hold the bottle
with both hands at
once, or when
nursing, does she
hold the breast with
her free hand?
OVERALL
1. Does your baby use both hands and both legs equally well? If no, explain.
o Yes
o No ________________________________________________
2. When you help your baby stand, are his feet flat on the surface most of the time? If no,
explain.
Page 12 of 139
o Yes
o No ________________________________________________
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?
If yes, explain.
o Yes ________________________________________________
o No
4. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
5. Do you have concerns about your baby's vision? If yes, explain.
o Yes ________________________________________________
o No
6. Has your baby had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
7. Do you have any concerns about your baby's behavior? If yes, explain.
o Yes ________________________________________________
o No
8. Does anything about your baby worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
Page 13 of 139
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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 at this time.
Other (specify): ________________________________________________
Page 14 of 139
ASQ-3 6-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Baby's date of birth (MM/DD/YYYY):
________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need? (e.g., autism, speech delay)
If yes, please specify.
o Yes ________________________________________________
o No
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 click 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.
• Make sure your baby is rested and fed.
COMMUNICATION
YES
SOMETIMES
NOT YET
1. Does your baby
make high-pitched
squeals?
o
o
o
2. When playing with
sounds, does your
baby make grunting,
o
o
o
Page 15 of 139
growling, or other
deep-toned sounds?
3. If you call your
baby when you are
out of sight, does she
look in the direction
of your voice?
4. When a loud noise
occurs, does your
baby turn to see
where the sound
came from?
5. Does your baby
make sounds like
"da," "ga," "ka," and
"ba"?
6. If you copy the
sound your baby
makes, does your
baby repeat the
same sounds back to
you?
o
o
o
o
o
o
o
o
o
o
o
o
GROSS MOTOR
YES
1. While your baby is
on his back, does
your baby lift his legs
high enough to see
his feet?
2. When your baby is
on her tummy, does
she straighten both
arms and push her
whole chest off the
bed or floor?
3. Does your baby
roll from his back to
his tummy, getting
both arms out from
under him?
4. When you put your
baby on the floor,
does she lean on her
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 16 of 139
hands while sitting?
(If she already sits up
straight without
leaning on her
hands, mark "YES"
for this item.)
5. If you hold both
hands just to balance
your baby, does he
support his own
weight while
standing?
6. Does your baby
get into a crawling
position by getting up
on her hands and
knees?
o
o
o
o
o
o
FINE MOTOR
YES
1. Does your baby
grab a toy you offer
and look at it, wave it
about, or chew on it
for about 1 minute?
2. Does your baby
reach for or grasp a
toy using both hands
at once?
3. Does your baby
reach for a crumb or
Cheerio and touch it
with his finger or
hand? (If he already
picks up a small
object the size of a
pea, mark "YES" for
this item.)
4. Does your baby
pick up a small toy,
holding it in the
center of her hand
with her fingers
around it?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 17 of 139
5. Does your baby try
to pick up a crumb or
Cheerio by using his
thumb and all of his
fingers in a raking
motion, even if he
isn't able to pick it
up? (If he already
picks up the crumb or
Cheerio, mark "YES"
for this item.)
6. Does your baby
pick up a small toy
with only one hand?
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. When a toy is in
front of your baby,
does she reach for it
with both hands?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
4. Does your baby
pick up a toy and put
it in his mouth?
o
o
o
5. Does your baby
pass a toy back and
forth from one hand
to the other?
o
o
o
6. Does your baby
play by banging a toy
up and down on the
o
o
o
2. When your baby is
on his back, does he
turn his head to look
for a toy when he
drops it? (If he
already picks it up,
mark "YES" for this
item.)
3. When your baby is
on her back, does
she try to get a toy
she has dropped if
she can see it?
Page 18 of 139
floor or table?
PERSONAL-SOCIAL
YES
1. When in front of a
large mirror, does
your baby smile or
coo at herself?
SOMETIMES
NOT YET
o
o
o
o
o
o
3. While lying on her
back, does your baby
play by grabbing her
foot?
o
o
o
4. When in front of a
large mirror, does
your baby reach out
to pat the mirror?
o
o
o
5. While your baby is
on his back, does he
put his foot in his
mouth?
o
o
o
o
o
o
2. Does your baby
act differently toward
strangers than he
does with you and
other familiar people?
(Reactions to
strangers may
include staring,
frowning,
withdrawing, or
crying.)
6. Does your baby try
to get a toy that is
out of reach? (She
may roll, pivot on her
tummy, or crawl to
get it.)
OVERALL
1. Does your baby use both hands and both legs equally well? If no, explain.
o Yes
o No ________________________________________________
Page 19 of 139
2. When you help your baby stand, are his feet flat on the surface most of the time? If no,
explain.
o Yes
o No ________________________________________________
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?
If yes, explain.
o Yes ________________________________________________
o No
4. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes________________________________________________
o No
5. Do you have concerns about your baby's vision? If yes, explain.
o Yes ________________________________________________
o No
6. Has your baby had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
7. Do you have any concerns about your baby's behavior? If yes, explain.
o Yes ________________________________________________
o No
8. Does anything about your baby worry you? If yes, explain.
o Yes ________________________________________________
o No
Page 20 of 139
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 21 of 139
ASQ-3 8-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Baby's date of birth (MM/DD/YYYY):
________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need? (e.g., autism, speech delay)
If yes, please specify.
o Yes ________________________________________________
o No
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 click 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.
• Make sure your baby is rested and fed.
COMMUNICATION
YES
1. If you call to your
baby when you are
out of sight, does she
look in the direction
of your voice?
o
SOMETIMES
o
NOT YET
o
Page 22 of 139
2. When a loud noise
occurs, does your
baby turn to see
where the sound
came from?
3. If you copy the
sounds your baby
makes, does your
baby repeat the
same sounds back to
you?
4. Does your baby
make sounds like
"da," "ga," "ka," and
"ba"?
5. Does your baby
respond to the tone
of your voice and
stop his activity at
least briefly when you
say "no-no" to him?
6. Does your baby
make two similar
sounds like "ba-ba,"
"da-da," or "ga-ga"?
(The sounds do not
need to mean
anything.)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
GROSS MOTOR
YES
1. When you put your
baby on the floor,
does she lean on her
hands while sitting?
(If she already sits up
straight without
leaning on her
hands, mark "YES"
for this item.)
2. Does your baby
roll from his back to
his tummy, getting
both arms out from
under him?
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 23 of 139
3. Does your baby
get into a crawling
position by getting up
on her hands and
knees?
4. If you hold both
hands just to balance
your baby, does he
support his own
weight while
standing?
5. When sitting on
the floor, does your
baby sit up straight
for several minutes
without using her
hands for support?
6. When you stand
your baby next to
furniture or the crib
rail, does he hold on
without leaning his
chest against the
furniture for support?
o
o
o
o
o
o
o
o
o
o
o
o
FINE MOTOR
YES
1. Does your baby
reach for a crumb or
Cheerio and touch it
with her finger or
hand? (If she
already picks up a
small object mark
"YES" for this item.)
2. Does your baby
pick up a small toy,
holding it in the
center of his hand
with his fingers
around it?
3. Does your baby try
to pick up a crumb or
Cheerio by using her
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
Page 24 of 139
thumb and all of her
fingers in a raking
motion, even if she
isn't able to pick it
up? (If she already
picks up a crumb or
Cheerio, mark "YES"
for this item.)
4. Does your baby
pick up a small toy
with only one hand?
5. Does your baby
successfully pick up
a crumb or Cheerio
by using his thumb
and all of his fingers
in a raking motion?
(If he already picks
up a crumb or
Cheerio, mark "YES"
for this item).
6. Does your baby
pick up a small toy
with the tips of her
thumb and fingers?
(You should see a
space between the
toy and her palm.)
o
o
o
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. Does your baby
pick up a toy and put
it in his mouth?
2. When your baby is
on her back, does
she try to get a toy
she has dropped if
she can see it?
3. Does your baby
play by banging a toy
up and down on the
floor or table?
4. Does your baby
pass a toy back and
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 25 of 139
forth from one hand
to the other?
5. Does your baby
pick up two small
toys, one in each
hand, and hold onto
them for about 1
minute?
6. When holding a
toy in his hand, does
your baby bang it
against another toy
on the table?
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
SOMETIMES
NOT YET
1. When lying on her
back, does your baby
play by grabbing her
foot?
o
o
o
2. When in front of a
large mirror, does
your baby reach out
to pat the mirror?
o
o
o
o
o
o
4. While your baby is
on her back, does
she put her foot in
her mouth?
o
o
o
5. Does your baby
drink water, juice, or
formula from a cup
while you hold it?
o
o
o
6. Does your baby
feed himself a
cracker or a cookie?
o
o
o
3. Does your baby try
to get a toy that is out
of reach? (He may
roll, pivot on his
tummy, or crawl to
get it.)
Page 26 of 139
OVERALL
1. Does your baby use both hands and both legs equally well? If no, explain.
o Yes
o No ________________________________________________
2. When you help your baby stand, are his feet flat on the surface most of the time? If no,
explain.
o Yes
o No ________________________________________________
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?
If yes, explain.
o Yes ________________________________________________
o No
4. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
5. Do you have concerns about your baby's vision? If yes, explain.
o Yes ________________________________________________
o No
6. Has your baby had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
7. Do you have any concerns about your baby's behavior? If yes, explain.
o Yes ________________________________________________
o No
Page 27 of 139
8. Does anything about your baby worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 28 of 139
ASQ-3 9-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Baby's date of birth (MM/DD/YYYY):
________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
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 click 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.
• Make sure your baby is rested and fed.
COMMUNICATION
YES
1. Does your baby
make sounds like
"da," "ga," "ka," and
"ba"?
o
SOMETIMES
o
NOT YET
o
Page 29 of 139
2. If you copy the
sounds your baby
makes, does your
baby repeat the
same sounds back to
you?
3. Does your baby
make two similar
sounds like "ba-ba,"
"da-da," or "ga-ga"?
(The sounds do not
need to mean
anything.)
4. 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")?
5. Does your baby
follow one simple
command, such as
"Come here," "Give it
to me," or "Put it
back," without your
using gestures?
6. 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.)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
GROSS MOTOR
YES
1. If you hold both
hands just to balance
your baby, does she
support her own
o
SOMETIMES
o
NOT YET
o
Page 30 of 139
weight while
standing?
2. When sitting on
the floor, does your
baby sit up straight
for several minutes
without using his
hands for support?
3. When you stand
your baby next to
furniture or the crib
rail, does she hold on
without leaning her
chest against the
furniture for support?
4. While holding onto
furniture, does your
baby bend down and
pick up a toy from the
floor and then return
to a standing
position?
5. While holding onto
furniture, does your
baby lower himself
with control (without
falling or flopping
down)?
6. Does your baby
walk beside furniture
while holding on with
only one hand?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
FINE MOTOR
YES
SOMETIMES
NOT YET
1. Does your baby
pick up a small toy
with only one hand?
o
o
o
2. Does your baby
successfully pick up
a crumb or Cheerio
by using her thumb
o
o
o
Page 31 of 139
and all of her fingers
in a raking motion?
(If she already picks
up a crumb or
Cheerio, mark "YES"
for this item.)
3. Does your baby
pick up a small toy
with the tips of his
thumb and fingers?
(You should see a
space between the
toy and his palm.)
4. After one or two
tries, does your baby
pick up a piece of
string with her first
finger and thumb?
(The string may be
attached to a toy.)
5. Does your baby
pick up a crumb or
Cheerio with the tips
of his thumb and a
finger? He may rest
his arm or hand on
the table while doing
it.
6. Does your baby
put a small toy down,
without dropping it,
and then take her
hand off the toy?
o
o
o
o
o
o
o
o
o
o
o
o
PROBLEM SOLVING
YES
SOMETIMES
NOT YET
1. Does your baby
pass a toy back and
forth from one hand
to the other?
o
o
o
2. Does your baby
pick up two small
toys, one in each
hand, and hold onto
o
o
o
Page 32 of 139
them for about 1
minute?
3. When holding a
toy in his hand, does
your baby bang it
against another toy
on the table?
4. While holding a
small toy in each
hand, does your baby
clap the toys together
(like "Pat-a-cake")?
5. 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)?
6. 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.)
o
o
o
o
o
o
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
SOMETIMES
NOT YET
1. While your baby is
on her back, does
she put her foot in
her mouth?
o
o
o
2. Does your baby
drink water, juice, or
formula from a cup
while you hold it?
o
o
o
3. Does your baby
feed himself a
cracker or a cookie?
o
o
o
o
o
o
4. When you hold out
your hand and ask
Page 33 of 139
for her toy, does your
baby offer it to you
even if she doesn't
let go of it? (If she
already lets go of the
toy into your hand,
mark "YES" for this
item.)
5. When you dress
your baby, does he
push his arm through
a sleeve once his
arm is started in the
hole of the sleeve?
6. When you hold out
your hand and ask
for her toy, does your
baby let go of it into
your hand?
o
o
o
o
o
o
OVERALL
1. Does your baby use both hands and both legs equally well? If no, explain.
o Yes
o No ________________________________________________
2. When you help your baby stand, are his feet flat on the surface most of the time? If no,
explain.
o Yes
o No ________________________________________________
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?
If yes, explain.
o Yes ________________________________________________
o No
4. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
Page 34 of 139
o No
5. Do you have concerns about your baby's vision? If yes, explain.
o Yes ________________________________________________
o No
6. Has your baby had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
7. Do you have any concerns about your baby's behavior? If yes, explain.
o Yes ________________________________________________
o No
8. Does anything about your baby worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for behavioral screening.
Refer to primary health care provider or other community agency (specify
reason): ________________________________________________
Page 35 of 139
▢
▢
▢
Refer to early intervention/early childhood special education.
No further action taken at this time.
Other (specify): ________________________________________________
Page 36 of 139
ASQ-3 10-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Baby's date of birth (MM/DD/YYYY):
________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
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 click 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.
• Make sure your baby is rested and fed.
COMMUNICATION
YES
1. Does your baby
make sounds like
"da," "ga," "ka," and
"ba"?
2. If you copy the
sounds your baby
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 37 of 139
makes, does your
baby repeat the
same sounds back to
you?
3. Does your baby
make two similar
sounds like "ba-ba,"
"da-da," or "ga-ga"?
(The sounds do not
need to mean
anything.)
4. 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")?
5. Does your baby
follow one simple
command, such as
"Come here," "Give it
to me," or "Put it
back," without your
using gestures?
6. 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.)
o
o
o
o
o
o
o
o
o
o
o
o
GROSS MOTOR
YES
1. If you hold both
hands just to balance
your baby, does she
support her own
weight while
standing?
o
SOMETIMES
o
NOT YET
o
Page 38 of 139
2. When sitting on
the floor, does your
baby sit up straight
for several minutes
without using his
hands for support?
3. When you stand
your baby next to
furniture or the crib
rail, does she hold on
without leaning her
chest against the
furniture for support?
4. While holding onto
furniture, does your
baby bend down and
pick up a toy from the
floor and then return
to a standing
position?
5. While holding onto
furniture, does your
baby lower himself
with control (without
falling or flopping
down)?
6. Does your baby
walk beside furniture
while holding on with
only one hand?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
FINE MOTOR
YES
1. Does your baby
pick up a small toy
with only one hand?
2. Does your baby
successfully pick up
a crumb or Cheerio
by using her thumb
and all of her fingers
in a raking motion?
(If she already picks
up a crumb or
Cheerio, mark "YES"
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 39 of 139
for this item.)
3. Does your baby
pick up a small toy
with the tips of his
thumb and fingers?
(You should see a
space between the
toy and his palm.)
4. After one or two
tries, does your baby
pick up a piece of
string with her first
finger and thumb?
(The string may be
attached to a toy.)
5. Does your baby
pick up a crumb or
Cheerio with the tips
of his thumb and a
finger? He may rest
his arm or hand on
the table while doing
it.
6. Does your baby
put a small toy down,
without dropping it,
and then take her
hand off the toy?
o
o
o
o
o
o
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. Does your baby
pass a toy back and
forth from one hand
to the other?
2. Does your baby
pick up two small
toys, one in each
hand, and hold onto
them for about 1
minute?
3. When holding a
toy in his hand, does
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
Page 40 of 139
your baby bang it
against another toy
on the table?
4. While holding a
small toy in each
hand, does your baby
clap the toys together
(like "Pat-a-cake")?
5. 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)?
6. 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.)
o
o
o
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
SOMETIMES
NOT YET
1. While your baby is
on her back, does
she put her foot in
her mouth?
o
o
o
2. Does your baby
drink water, juice, or
formula from a cup
while you hold it?
o
o
o
3. Does your baby
feed himself a
cracker or a cookie?
o
o
o
o
o
o
4. When you hold out
your hand and ask
for her toy, does your
baby offer it to you
even if she doesn't
let go of it? (If she
already lets go of the
Page 41 of 139
toy into your hand,
mark "YES" for this
item.)
5. When you dress
your baby, does he
push his arm through
a sleeve once his
arm is started in the
hole of the sleeve?
6. When you hold out
your hand and ask
for her toy, does your
baby let go of it into
your hand?
o
o
o
o
o
o
OVERALL
1. Does your baby use both hands and both legs equally well? If no, explain.
o Yes
o No ________________________________________________
2. When you help your baby stand, are his feet flat on the surface most of the time? If no,
explain.
o Yes
o No ________________________________________________
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?
If yes, explain.
o Yes________________________________________________
o No
4. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
5. Do you have concerns about your baby's vision? If yes, explain.
Page 42 of 139
o Yes________________________________________________
o No
6. Has your baby had any medical problems in the last several months? If yes, explain.
o Yes________________________________________________
o No
7. Do you have any concerns about your baby's behavior? If yes, explain.
o Yes________________________________________________
o No
8. Does anything about your baby worry you? If yes, explain.
o Yes________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for behavioral screening.
Refer to primary health care provider or other community agency (specify
reason):________________________________________________
▢
Refer to early intervention/early childhood special education.
Page 43 of 139
▢
▢
No further action taken tat this time.
Other (specify): ________________________________________________
Page 44 of 139
ASQ-3 12-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Baby's date of birth (MM/DD/YYYY):
________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
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 click 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.
• Make sure your baby is rested and fed.
COMMUNICATION
YES
1. Does your baby
make two similar
sounds, such as "baba," "da-da," or "gaga"? (The sounds do
not need to mean
anything.)
o
SOMETIMES
o
NOT YET
o
Page 45 of 139
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?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
GROSS MOTOR
YES
1. While holding onto
furniture, does your
baby bend down and
pick up a toy from the
o
SOMETIMES
o
NOT YET
o
Page 46 of 139
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?
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?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
FINE MOTOR
YES
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
o
SOMETIMES
o
NOT YET
o
Page 47 of 139
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.)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. When holding a
small toy in each
hand, does your baby
clap the toys together
(like "Pat-a-cake")?
o
SOMETIMES
o
NOT YET
o
Page 48 of 139
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.)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
1. When you hold out
your hand and ask
o
SOMETIMES
o
NOT YET
o
Page 49 of 139
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?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Does your baby use both hands and both legs equally well? If no, explain.
o Yes
o No ________________________________________________
2. Does your baby play with sounds or seem to make words? If no, explain.
o Yes
Page 50 of 139
o No ________________________________________________
3. When your baby is standing, are her feet flat on the surface most of the time? If no, explain.
o Yes
o No________________________________________________
4. Do you have concerns that your baby is too quiet or does not make sounds like other babies
do? If yes, explain.
o Yes ________________________________________________
o No
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
6. Do you have concerns about your baby's vision? If yes, explain.
o Yes ________________________________________________
o No
7. Has your baby had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
8. Do you have any concerns about your baby's behavior? If yes, explain.
o Yes ________________________________________________
o No
9. Does anything about your baby worry you? If yes, explain.
o Yes ________________________________________________
o No
Page 51 of 139
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 52 of 139
ASQ-3 14-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Baby's date of birth (MM/DD/YYYY):
________________________________________________
If baby was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Baby's sex
o Male
o Female
Does the baby have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
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 click 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.
• Make sure your baby is rested and fed.
At this age, many toddlers may not be cooperative when asked to do things. You may need to
try the following activities with your baby more than one time. If possible, try the activities when
your baby is cooperative. If your baby can do the activity but refuses, mark "YES" for the item.
COMMUNICATION
YES
SOMETIMES
NOT YET
Page 53 of 139
1. 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.)
o
o
o
2. When your baby
wants something,
does she tell you by
pointing to it?
o
o
o
3. Does your baby
shake his head when
he means "no" or
"yes"?
o
o
o
4. Does your baby
point to, pat, or try to
pick up pictures in a
book?
o
o
o
5. Does your baby
say four or more
words in addition to
"Mama" and "Dada"?
o
o
o
o
o
o
6. When you ask her
to, does your baby
go into another room
to find a familiar toy
or object? (You
might ask, "Where is
your ball?" or say,
"Bring me your coat,"
or "Go get your
blanket.")
GROSS MOTOR
YES
1. 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
o
SOMETIMES
o
NOT YET
o
Page 54 of 139
item.)
2. 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.)
3. Does your baby
stand up in the
middle of the floor by
himself and take
several steps
forward?
4. Does your baby
climb onto furniture
or other large
objects, such as
large climbing
blocks?
5. Does your baby
bend over or squat to
pick up an object
from the floor and
then stand up again
without any support?
6. Does your baby
move around by
walking, rather than
by crawling on his
hands and knees?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
FINE MOTOR
YES
1. 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?
2. Does your baby
throw a small ball
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 55 of 139
with a forward arm
motion? (If he simply
drops the ball, mark
"NOT YET" for this
item.)
3. Does your baby
help turn the pages
of a book? (You may
lift a page for her to
grasp.)
4. Does your baby
stack a small block or
toy on top of another
one? (You could
also use spools of
thread, small boxes,
or toys that are about
1 inch in size.)
5. Does your baby
make a mark on the
paper with the tip of a
crayon (or pencil or
pen) when trying to
draw?
6. Does your baby
stack three small
blocks or toys on top
of each other by
herself?
o
o
o
o
o
o
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. If you put a small
toy into a bowl or
box, does your baby
copy you by putting
in a toy, although he
may not let go of it?
(If he already lets go
of the toy into a bowl
or box, mark "YES"
for this item.)
o
SOMETIMES
o
NOT YET
o
Page 56 of 139
2. Does your baby
drop two small toys,
one after the other,
into a container like a
bowl or box? (You
may show her how to
do it.)
3. After you scribble
back and forth on
paper with a crayon
(or a pencil or pen),
does your baby copy
you by scribbling? (If
he already scribbles
on his own, mark
"YES" for this item.)
4. Can your baby
drop a crumb or
Cheerio into a small,
clear bottle (such as
a plastic soda-pop
bottle or baby
bottle)?
5. Does your baby
drop several small
toys, one after
another, into a
container like a bowl
or box? (You may
show her how to do
it.)
6. After you have
shown your baby
how, does he try to
get a small toy that is
slightly out of reach
by using a spoon,
stick, or similar tool?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
1. When you dress
your baby, does she
lift her foot for her
shoe, sock, or pant
leg?
o
SOMETIMES
o
NOT YET
o
Page 57 of 139
2. Does your baby
roll or throw a ball
back to you so that
you can return it to
him?
3. Does your baby
play with a doll or
stuffed animal by
hugging it?
4. Does your baby
feed herself with a
spoon, even though
she may spill some
food?
5. Does your baby
help undress himself
by taking off clothes
like socks, hat,
shoes, or mittens?
6. Does your baby
get your attention or
try to show you
something by pulling
on your hand or
clothes?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Does your baby use both hands and both legs equally well? If no, explain.
o Yes
o No________________________________________________
2. Does your baby play with sounds or seem to make words? If no, explain.
o Yes
o No ________________________________________________
3. When your baby is standing, are her feet flat on the surface most of the time? If no, explain.
o Yes
Page 58 of 139
o No ________________________________________________
4. Do you have concerns that your baby is too quiet or does not make sounds like other babies
do? If yes, explain.
o Yes ________________________________________________
o No
5. Does either parent have a history of childhood deafness or hearing impairment? If yes,
explain.
o Yes________________________________________________
o No
6. Do you have concerns about your baby's vision? If yes, explain.
o Yes ________________________________________________
o No
7. Has your baby had any medical problems in the last several months? If yes, explain.
o Yes________________________________________________
o No
8. Do you have any concerns about your baby's behavior? If yes, explain.
o Yes ________________________________________________
o No
9. Does anything about your baby worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
Page 59 of 139
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 60 of 139
ASQ-3 16-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
If child was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
At this age, many toddlers may not be cooperative when asked to do things. You may need to
try the following activities with your child more than one time. If possible, try the activities when
your child is cooperative. If your child can do the activity but refuses, mark "YES" for the item.
COMMUNICATION
YES
SOMETIMES
NOT YET
Page 61 of 139
1. Does your child
point to, pat, or try to
pick up pictures in a
book?
o
o
o
2. Does your child
say four or more
words in addition to
"Mama" and "Dada"?
o
o
o
3. When your child
wants something,
does she tell you by
pointing to it?
o
o
o
o
o
o
o
o
o
o
o
o
4. When you ask
your child to, does he
go into another room
to find a familiar toy
or object? (You
might ask, "Where is
your ball?" or say,
"Bring me your coat,"
or "Go get your
blanket.")
5. Does your child
imitate a two-word
sentence? For
example, when you
say a two-word
phrase, such as
"Mama eat," "Daddy
play," "Go home," or
"What's this?" does
your child say both
words back to you?
(Mark "YES" even if
her words are difficult
to understand.)
6. Does your child
say eight or more
words in addition to
"Mama" and "Dada"?
GROSS MOTOR
YES
SOMETIMES
NOT YET
Page 62 of 139
1. Does your child
stand up in the
middle of the floor by
himself and take
several steps
forward?
2. Does your child
climb onto furniture
or other large
objects, such as
large climbing
blocks?
3. Does your child
bend over or squat to
pick up an object
from the floor and
then stand up again
without any support?
4. Does your child
move around by
walking, rather than
crawling on her
hands and knees?
5. Does your child
walk well and seldom
fall?
6. Does your child
climb on an object
such as a chair to
reach something he
wants (for example,
to get a toy on a
counter or to "help"
you in the kitchen)?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
FINE MOTOR
YES
1. Does your child
help turn the pages
of a book? (You may
lift a page for her to
grasp.)
o
SOMETIMES
o
NOT YET
o
Page 63 of 139
2. Does your child
throw a small ball
with a forward arm
motion? (If he simply
drops the ball, mark
"NOT YET" for this
item.)
3. Does your child
stack a small block or
toy on top of another
one? (You could
also use spools of
thread, small boxes,
or toys that are about
1 inch in size.)
4. Does your child
stack three small
blocks or toys on top
of each other by
herself?
5. Does your child
make a mark on the
paper with the tip of a
crayon (or pencil or
pen) when trying to
draw?
6. Does your child
turn the pages of a
book by himself?
(He may turn more
than one page at a
time.)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. After you scribble
back and forth on
paper with a crayon
(or pencil or pen),
does your child copy
you by scribbling? (If
she already scribbles
on her own, mark
"YES" for this item.)
o
SOMETIMES
o
NOT YET
o
Page 64 of 139
2. Can your child
drop a crumb or
Cheerio into a small,
clear bottle (such as
a plastic soda-pop
bottle or baby
bottle)?
3. Does your child
drop several small
toys, one after
another, into a
container like a bowl
or box? (You may
show him how to do
it.)
4. After you have
shown your child
how, does she try to
get a small toy that is
slightly out of reach
by using a spoon,
stick, or similar tool?
5. Without your
showing him how,
does your child
scribble back and
forth when you give
him a crayon (or
pencil or pen)?
6. After a crumb or
Cheerio is dropped
into a small, clear
bottle, does your
child turn the bottle
upside down to dump
it out? (You may
show her how.)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
1. Does your child
feed himself with a
spoon, even though
he may spill some
food?
o
SOMETIMES
o
NOT YET
o
Page 65 of 139
2. Does your child
help undress herself
by taking off clothes
like socks, hat,
shoes, or mittens?
3. Does your child
play with a doll or
stuffed animal by
hugging it?
4. While looking at
himself in the mirror,
does your child offer
a toy to his own
image?
5. Does your child
get your attention or
try to show you
something by pulling
on your hand or
clothes?
6. Does your child
come to you when
she needs help, such
as with winding up a
toy or unscrewing a
lid from a jar?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers his age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
Page 66 of 139
4. Do you think your child walks, runs, and climbs like other toddlers her age? If no, explain.
o Yes
o No________________________________________________
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes________________________________________________
o No
6. Do you have concerns about your child's vision? If yes, explain.
o Yes ________________________________________________
o No
7. Has your child had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
8. Do you have any concerns about your child's behavior? If yes, explain.
o Yes ________________________________________________
o No
9. Does anything about your child worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): (1) ________________________________________________
Page 67 of 139
▢
▢
▢
▢
▢
Share results with primary health care provider. (2)
Refer for hearing screening. (3)
Refer for vision screening. (4)
Refer for behavioral screening. (5)
Refer to primary health care provider or other community agency (specify
reason): (6) ________________________________________________
▢
▢
▢
Refer to early intervention/early childhood special education. (7)
No further action taken at this time. (8)
Other (specify): (9) ________________________________________________
Page 68 of 139
ASQ-3 18-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
If child was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
At this age, many toddlers may not be cooperative when asked to do things. You may need to
try the following activities with your child more than one time. If possible, try the activities when
your child is cooperative. If your child can do the activity but refuses, mark "YES" for the item.
COMMUNICATION
YES
1. When your child
wants something,
does she tell you by
o
SOMETIMES
o
NOT YET
o
Page 69 of 139
pointing to it?
2. When you ask
your child to, does he
go into another room
to find a familiar toy
or object? (You
might ask, "Where is
your ball?" or say,
"Bring me your coat,"
or "Go get your
blanket.")
3. Does your child
say eight or more
words in addition to
"Mama" and "Dada"?
4. Does your child
imitate a two-word
sentence? For
example, when you
say a two-word
phrase, such as
"Mama eat," "Daddy
play," "Go home," or
"What's this?" does
your child say both
words back to you?
(Mark "YES" even if
her words are difficult
to understand.)
5. Without your
showing him, does
your child point to the
correct picture when
you say, "Show me
the kitty," or ask,
"Where is the dog?"
(He needs to identify
only one picture
correctly.)
6. Does your child
say two or three
words that represent
different ideas
together, such as
"See dog," "Mommy
come home," or
"Kitty gone"? (Don't
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 70 of 139
count word
combinations that
express one idea,
such as "bye-bye,"
"all gone," "all right,"
and "What's that?")
GROSS MOTOR
YES
1. Does your child
bend over or squat to
pick up an object
from the floor and
then stand up again
without any support?
2. Does your child
move around by
walking, rather than
by crawling on her
hands and knees?
3. Does your child
walk well and seldom
fall?
4. Does your child
climb on an object
such as a chair to
reach something he
wants (for example,
to get a toy on a
counter or to "help"
you in the kitchen)?
5. Does your child
walk down stairs if
you hold onto one of
her hands? She may
also hold onto the
railing or wall. (You
can look for this at a
store, on a
playground, or at
home.)
6. When you show
your child how to kick
a large ball, does he
try to kick the ball by
moving his leg
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 71 of 139
forward or by walking
into it? (If your child
already kicks a ball,
mark "YES" for this
item.)
FINE MOTOR
YES
1. Does your child
throw a small ball
with a forward arm
motion? (If he simply
drops the ball, mark
"NOT YET" for this
item.)
2. Does your child
stack a small block or
toy on top of another
one? (You could
also use spools of
thread, small boxes,
or toys that are about
1 inch in size.)
3. Does your child
make a mark on the
paper with the tip of a
crayon (or pencil or
pen) when trying to
draw?
4. Does your child
stack three small
blocks or toys on top
of each other by
himself?
5. Does your child
turn the pages of a
book by himself?
(He may turn more
than one page at a
time.)
6. Does your child
get a spoon into her
mouth right side up
so that the food
usually doesn't spill?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 72 of 139
PROBLEM SOLVING
YES
1. Does your child
drop several small
toys, one after
another, into a
container like a bowl
or box? (You may
show him how to do
it.)
2. After you have
shown your child
how, does she try to
get a small toy that is
slightly out of reach
by using a spoon,
stick, or similar tool?
3. After a crumb or
Cheerio is dropped
into a small, clear
bottle, does your
child turn the bottle
over to dump it out?
(You may show him
how.) (You can use a
soda-pop bottle or a
baby bottle.)
4. Without your
showing her how,
does your child
scribble back and
forth when you give
her a crayon (or
pencil or pen)?
5. After watching you
draw a line from the
top of the paper to
the bottom with a
crayon (or pencil or
pen), does your child
copy you by drawing
a single line on the
paper in any
direction? (Mark
"NOT YET" if your
child scribbles back
and forth.)
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 73 of 139
6. After a crumb or
Cheerio is dropped
into a small, clear
bottle, does your
child turn the bottle
upside down to dump
out the crumb or
Cheerio? (Do not
show him how.)
o
o
o
PERSONAL-SOCIAL
YES
1. While looking at
herself in the mirror,
does your child offer
a toy to her own
image?
2. Does your child
play with a doll or
stuffed animal by
hugging it?
3. Does your child
get your attention or
try to show you
something by pulling
on your hand or
clothes?
4. Does your child
come to you when he
needs help, such as
with winding up a toy
or unscrewing a lid
from a jar?
5. Does your child
drink from a cup or
glass, putting it down
again with little
spilling?
6. Does your child
copy the activities
you do, such as wipe
up a spill, sweep,
shave, or comb hair?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 74 of 139
OVERALL
1. Do you think your child hears well? If no, explain.
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers his age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
4. Do you think your child walks, runs, and climbs like other toddlers her age? If no, explain.
o Yes
o No________________________________________________
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
6. Do you have concerns about your child's vision? If yes, explain.
o Yes ________________________________________________
o No
7. Has your child had any medical problems in the last several months? If yes, explain.
o Yes________________________________________________
o No
8. Do you have any concerns about your child's behavior? If yes, explain.
Page 75 of 139
o Yes________________________________________________
o No
9. Does anything about your child worry you? If yes, explain.
o Yes________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 76 of 139
ASQ-3 20-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
If child was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
At this age, many toddlers may not be cooperative when asked to do things. You may need to
try the following activities with your child more than one time. If possible, try the activities when
your child is cooperative. If your child can do the activity but refuses, mark "YES" for the item.
COMMUNICATION
YES
SOMETIMES
NOT YET
Page 77 of 139
1. Does your child
imitate a two-word
sentence? For
example, when you
say a two-word
phrase, such as
"Mama eat, " "Daddy
play," "Go home," or
"What's this?" does
your child say both
words back to you?
(Mark "YES" even if
her words are difficult
to understand.)
2. Does your child
say eight or more
words in addition to
"Mama" and "Dada"?
3. Without your
showing him, does
your child point to the
correct picture when
you say, "Show me
the kitty," or ask,
"Where is the dog?"
(He needs to identify
only one picture
correctly.)
4. If you point to a
picture of a ball (kitty,
cup, hat, etc.) and
ask your child, "What
is this?" does your
child correctly name
at least one picture?
5. Without your
giving him clues by
pointing or using
gestures, can your
child carry out at
least three of these
kinds of directions?
a. "Put the toy on the
table."
b. "Close the door."
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
c. "Bring me a towel."
Page 78 of 139
d. "Find your coat."
e. "Take my hand."
f. "Get your book."
6. Does your child
say two or three
words that represent
different ideas
together, such as
"See dog," "Mommy
come home," or
"Kitty gone"? (Don't
count word
combinations that
express one idea,
such as "bye-bye,"
"all gone," "all right,"
and "What's that?")
o
o
o
GROSS MOTOR
YES
1. Does your child
climb on an object
such as a chair to
reach something he
wants (for example,
to get a toy on a
counter or to "help"
you in the kitchen)?
2. Does your child
walk well and seldom
fall?
3. Does your child
walk down stairs if
you hold onto one of
her hands? She may
also hold onto the
railing or wall. (You
can look for this at a
store, on a
playground, or at
home.)
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
Page 79 of 139
4. When you show
your child how to kick
a large ball, does he
try to kick the ball by
moving his leg
forward or by walking
into it? (If your child
already kicks a ball,
mark "YES" for this
item.)
5. Does your child
run fairly well,
stopping herself
without bumping into
things or falling?
6. Does your child
walk either up or
down at least two
steps by himself? He
may also hold onto
the railing or wall.
o
o
o
o
o
o
o
o
o
FINE MOTOR
YES
1. Does your child
make a mark on the
paper with the tip of a
crayon (or pencil or
pen) when trying to
draw?
2. Does your child
stack three small
blocks or toys on top
of each other by
herself? (You could
also use spools of
thread, small boxes,
or toys that are about
1 inch in size.)
3. Does your child
turn the pages of a
book by himself? (He
may turn more than
one page at a time.)
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
Page 80 of 139
4. Does your child
get a spoon into her
mouth right side up
so that the food
usually doesn't spill?
5. Does your child
stack six small blocks
or toys on top of each
other by himself?
6. Does your child
use a turning motion
with her hand while
trying to turn
doorknobs, wind up
toys, twist tops, or
screw lids on and off
jars?
o
o
o
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. Without your
showing him how,
does your child
scribble back and
forth when you give
him a crayon (or
pencil or pen)?
2. After watching you
draw a line from the
top of the paper to
the bottom with a
crayon (or pencil or
pen), does your child
copy you by drawing
a single line on the
paper in any
direction? (Mark
"NOT YET" if your
child scribbles back
and forth.)
3. If you do any of the
following gestures,
does your child copy
at least one of them?
a. Open and close
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
Page 81 of 139
your mouth.
b. Blink your eyes.
c. Pull on your
earlobe.
d. Pat your check.
4. If you give your
child a bottle, spoon,
or pencil upside
down, does she turn
it right side up so that
she can use it
properly?
5. While your child
watches, line up four
objects like blocks or
cars in a row. Does
your child copy or
imitate you and line
up at least two blocks
side by side? (You
can also use spools
of thread, small
boxes, or other toys.)
6. If your child wants
something he cannot
reach, does he find a
chair or box to stand
on to reach it (for
example, to get a toy
on a counter or to
"help" you in the
kitchen)?
o
o
o
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
1. Does your child
feed herself with a
spoon, even though
she may spill some
food?
2. Does your child
get your attention or
try to show you
something by pulling
on your hand or
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 82 of 139
clothes?
3. Does your child
drink from a cup or
glass, putting it down
again with little
spilling?
4. Does your child
copy the activities
you do, such as wipe
up a spill, sweep,
shave, or comb hair?
5. When playing with
either a stuffed
animal or a doll, does
your child pretend to
rock it, feed it,
change its diapers,
put it to bed, and so
forth?
6. Does your child
eat with a fork?
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers her age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
4. Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain.
o Yes
Page 83 of 139
o No ________________________________________________
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
6. Do you have any concerns about your child's vision? If yes, explain.
o Yes________________________________________________
o No
7. Has your child had any medical problems in the last several months? If yes, explain.
o Yes________________________________________________
o No
8. Do you have any concerns about your child's behavior? If yes, explain.
o Yes ________________________________________________
o No
9. Does anything about your child worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen): ________________________________________________
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Page 84 of 139
▢
▢
▢
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 85 of 139
ASQ-3 22-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
If child was born 3 or more weeks prematurely, # of weeks premature:
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
At this age, many toddlers may not be cooperative when asked to do things. You may need to
try the following activities with your child more than one time. If possible, try the activities when
your child is cooperative. If your child can do the activity but refuses, mark "YES" for the item.
COMMUNICATION
YES
1. If you point to a
picture of a ball (kitty,
cup, hat, etc.) and
o
SOMETIMES
o
NOT YET
o
Page 86 of 139
ask your child, "What
is this?" does your
child correctly name
at least one picture?
2. Without your
giving him clues by
pointing or using
gestures, can your
child carry out at
least three of these
kinds of directions?
a. "Put the toy on the
table."
b. "Close the door."
c. "Bring me a towel."
d. "Find your coat."
e. "Take my hand."
f. "Get your book."
3. When you ask
your child to point to
her nose, eyes, hair,
feet, ears, and so
forth, does she
correctly point to at
least seven body
parts? (She can point
to parts of herself,
you, or a doll. Mark
"SOMETIMES" if she
correctly points to at
least three different
body parts.)
4. Does your child
say 15 or more
words in addition to
"Mama" and "Dada"?
5. Does your child
correctly use at least
two words like "me,"
"I," "mine," and
"you"?
6. Does your child
say two or three
words that represent
different ideas
together, such as
"See dog," "Mommy
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 87 of 139
come home," or
"Kitty gone"? (Don't
count word
combinations that
express one idea,
such as "bye-bye,"
"all gone," "all right,"
and "What's that?")
GROSS MOTOR
YES
1. When you show
your child how to kick
a large ball, does he
try to kick the ball by
moving his leg
forward or by walking
into it? (If your child
already kicks a ball,
mark "YES" for this
item.)
2. Does your child
run fairly well,
stopping herself
without bumping into
things or falling?
3. Does your child
walk down stairs if
you hold onto one of
his hands? He may
also hold onto the
railing or wall. (You
can look for this at a
store, on a
playground, or at
home.)
4. Does your child
walk either up or
down at least two
steps by herself?
She may hold onto
the railing or wall.
5. Does your child
jump with both feet
leaving the floor at
the same time?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 88 of 139
6. Without holding
onto anything for
support, does your
child kick a ball by
swinging his leg
forward?
o
o
o
FINE MOTOR
YES
1. Does your child
get a spoon into her
mouth right side up
so that the food
usually doesn't spill?
2. Does your child
stack six small blocks
or toys on top of each
other by himself?
(You could also use
spools of thread,
small boxes, or toys
that are about 1 inch
in size.)
3. Does your child
use a turning motion
with her hand while
trying to turn
doorknobs, wind up
toys, twist tops, or
screw lids on and off
jars?
4. Does your child
turn the pages of a
book by himself? (He
may turn more than
one page at a time.)
5. Does your child flip
switches off and on?
6. Can your child
string small items
such as beads,
macaroni, or pasta
"wagon wheels" onto
a string or shoelace?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 89 of 139
PROBLEM SOLVING
YES
1. Without your
showing her how,
does your child
scribble back and
forth when you give
her a crayon (or
pencil or pen)?
2. While your child
watches, line up four
objects like blocks or
cars in a row. Does
your child copy or
imitate you and line
up at least two blocks
side by side? (You
can also use spools
of thread, small
boxes, or other toys.)
3. Does your child
pretend objects are
something else? For
example, does your
child hold a cup to his
ear, pretending it is a
telephone? Does he
put a box on his
head, pretending it is
a hat? Does he use
a block or small toy
to stir food?
4. After watching you
draw a line from the
top of the paper to
the bottom with a
crayon (or pencil or
pen), does your child
copy you by drawing
a single line on the
paper in any
direction? (Mark
"NOT YET" if your
child scribbles back
and forth.)
5. After a crumb or
Cheerio is dropped
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 90 of 139
into a small, clear
bottle, does your
child turn the bottle
upside down to dump
out the crumb or
Cheerio? (Do not
show her how.) (You
can use a soda-pop
bottle or a baby
bottle.)
6. If you give your
child a bottle, spoon,
or pencil upside
down, does he turn it
right side up so that
he can use it
properly?
o
o
o
PERSONAL-SOCIAL
YES
1. Does your child
copy the activities
you do, such as wipe
up a spill, sweep,
shave, or comb hair?
2. If you do any of
the following
gestures, does your
child copy at least
one of them?
a. "Open and close
your mouth."
b. "Blink your eyes."
c. "Pull on your
earlobe."
d. "Pat your cheek."
3. Does your child
eat with a fork?
4. Does your child
drink from a cup or
glass, putting it down
again with little
spilling?
5. When playing with
either a stuffed
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 91 of 139
animal or doll, does
your child pretend to
rock it, feed it,
change its diapers,
put it to bed, and so
forth?
6. Does your child
push a little wagon,
stroller, or other toy
on wheels, steering it
around objects and
backing out of
corners if she cannot
turn?
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers her age? If no, explain.
o Yes
o No________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
4. Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain.
o Yes
o No________________________________________________
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
Page 92 of 139
6. Do you have concerns about your child's vision? If yes, explain.
o Yes ________________________________________________
o No
7. Has your child had any medical problems in the last several months? If yes, explain.
o Yes________________________________________________
o No
8. Do you have any concerns about your child's behavior? If yes, explain.
o Yes________________________________________________
o No
9. Does anything about your child worry you? If yes, explain.
o Yes________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for behavioral screening.
Refer to primary health care provider or other community agency (specify
reason): ________________________________________________
Page 93 of 139
▢
▢
▢
Refer to early intervention/early childhood special education.
No further action taken at this time.
Other (specify): ________________________________________________
Page 94 of 139
ASQ-3 24-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
At this age, many toddlers may not be cooperative when asked to do things. You may need to
try the following activities with your child more than one time. If possible, try the activities when
your child is cooperative. If your child can do the activity but refuses, mark "YES" for the item.
COMMUNICATION
YES
1. Without your
showing him, does
your child point to the
correct picture when
you say, "Show me
the kitty," or ask,
o
SOMETIMES
o
NOT YET
o
Page 95 of 139
"Where is the dog?"
(She needs to
identify only one
picture correctly.)
2. Does your child
imitate a two-word
sentence? For
example, when you
say a two-word
phrase, such as
"Mama eat," "Daddy
play," "Go home," or
"What's this?" does
your child say both
words back to you?
(Mark "YES" even if
her words are difficult
to understand.)
3. Without your
giving him clues by
pointing or using
gestures, can your
child carry out at
least three of these
kinds of directions?
a. "Put the toy on the
table."
b. "Close the door."
c. "Bring me a towel."
d. "Find your coat."
e. "Take my hand."
f. "Get your book."
4. If you point to a
picture of a ball (kitty,
cup, hat, etc.) and
ask your child, "What
is this?" does your
child correctly name
at least one picture?
5. Does your child
say two or three
words that represent
different ideas
together, such as
"See dog," "Mommy
come home," or
"Kitty gone"? (Don't
count word
o
o
o
o
o
o
o
o
o
o
o
o
Page 96 of 139
combinations that
express one idea,
such as "bye-bye,"
"all gone," "all right,"
and "What's that?")
6. Does your child
correctly use at least
two words like "me,
"I," "mine," and
"you"?
o
o
o
GROSS MOTOR
YES
1. Does your child
walk down stairs if
you hold onto one of
her hands? She may
also hold onto the
railing or wall. (You
can look for this at a
store, on a
playground, or at
home.)
2. When you show
your child how to kick
a large ball, does he
try to kick the ball by
moving his leg
forward or by walking
into it? (If your child
already kicks a ball,
mark "YES" for this
item.)
3. Does your child
walk either up or
down at least two
steps by herself?
She may hold onto
the railing or wall.
4. Does your child
run fairly well,
stopping herself
without bumping into
things or falling?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 97 of 139
5. Does your child
jump with both feet
leaving the floor at
the same time?
6. Without holding
onto anything for
support, does your
child kick a ball by
swinging his leg
forward?
o
o
o
o
o
o
FINE MOTOR
YES
1. Does your child
get a spoon into his
mouth right side up
so that the food
usually doesn't spill?
2. Does your child
turn the pages of a
book by herself?
(She may turn more
than one page at a
time.)
3. Does your child
use a turning motion
with his hand while
trying to turn
doorknobs, wind up
toys, twist tops, or
screw lids on and off
jars?
4. Does your child flip
switches off and on?
5. Does your child
stack seven small
blocks or toys on top
of each other by
herself? (You could
also use spools of
thread, small boxes,
or toys that are about
1 inch in size.)
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 98 of 139
6. Can your child
string small items
such as beads,
macaroni, or pasta
"wagon wheels" onto
a string or shoelace?
o
o
o
PROBLEM SOLVING
YES
1. After watching you
draw a line from the
top of the paper to the
bottom with a crayon
(or pencil or pen),
does your child copy
you by drawing a
single line on the
paper in any
direction? (Mark "NOT
YET" if your child
scribbles back and
forth.)
2. After a crumb or
Cheerio is dropped
into a small, clear
bottle, does your child
turn the bottle upside
down to dump out the
crumb or Cheerio?
(Do not show him
how.) (You can use a
soda-pop bottle or
baby bottle.)
3. Does your child
pretend objects are
something else? For
example, does your
child hold a cup to her
ear, pretending it is a
telephone? Does she
put a box on her
head, pretending it is
a hat? Does she use
a block or small toy to
stir food?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
Page 99 of 139
4. Does your child put
things away where
they belong? For
example, does he
know his toys belong
on the toy shelf, his
blanket goes on his
bed, and dishes go in
the kitchen?
5. If your child wants
something she cannot
reach, does she find a
chair or box to stand
on to reach it (for
example, to get a toy
on a counter or "help"
you in the kitchen)?
6. While your child
watches, line up four
objects like blocks or
cars in a row. Does
your child copy or
imitate you and line
up four objects in a
row? (You can also
use spools of thread,
small boxes, or other
toys.)
o
o
o
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
1. Does your child
drink from a cup or
glass, putting it down
again with little
spilling?
2. Does your child
copy the activities you
do, such as wipe up a
spill, sweep, shave, or
comb hair?
3. Does your child eat
with a fork?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
Page 100 of 139
4. When playing with
either a stuffed animal
or doll, does your
child pretend to rock
it, feed it, change its
diapers, put it to bed,
and so forth?
5. Does your child
push a little wagon,
stroller, or other toy
on wheels, steering it
around objects and
backing out of corners
if he cannot turn?
6. Does your child call
herself "I" or "me"
more often than her
own name? For
example, "I do it,"
more often than
"Juanita do it."
o
o
o
o
o
o
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers her age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
4. Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain.
o Yes
Page 101 of 139
o No ________________________________________________
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
6. Do you have any concerns about your child's vision? If yes, explain.
o Yes ________________________________________________
o No
7. Has your child had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
8. Do you have any concerns about your child's behavior? If yes, explain.
o Yes ________________________________________________
o No
9. Does anything about your child worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Page 102 of 139
▢
▢
▢
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 103 of 139
ASQ-3 27-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
At this age, many toddlers may not be cooperative when asked to do things. You may need to
try the following activities with your child more than one time. If possible, try the activities when
your child is cooperative. If your child can do the activity but refuses, mark "YES" for the item.
COMMUNICATION
YES
1. Without your
giving him clues by
pointing or using
gestures, can your
child carry out at
o
SOMETIMES
o
NOT YET
o
Page 104 of 139
least three of these
kinds of directions?
a. "Put the toy on the
table."
b. "Close the door."
c. "Bring me a
towel."
d. "Find your coat."
e. "Take my hand."
f. "Get your book."
2. If you point to a
picture of a ball (kitty,
cup, hat, etc.) and
ask your child, "What
is this?" does your
child correctly name
at least one picture?
3. When you ask her
to point to her nose,
eyes, hair, feet, ears,
and so forth, does
your child correctly
point to at least
seven body parts?
(She can point to
parts of herself, you,
or a doll. Mark
"SOMETIMES" if she
correctly points to at
least three different
body parts.)
4. Does your child
correctly use at least
two words like "me,"
"I," "mine," and
"you"?
5. Does your child
make sentences that
are three or four
words long?
6. Without giving
your child help by
pointing or using
gestures, ask him to
"put the book on the
table" and "put the
shoe under the
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 105 of 139
chair." Does your
child carry out both of
these directions
correctly?
GROSS MOTOR
YES
1. Does your child
walk either up or
down at least two
steps by himself? He
may hold onto the
railing or wall. (You
can look for this at a
store, on a
playground, or at
home.)
2. Does your child
run fairly well,
stopping herself
without bumping into
things or falling?
3. Does your child
jump with both feet
leaving the floor at
the same time?
4. Without holding
onto anything for
support, does your
child kick a ball by
swinging his leg
forward?
5. Does your child
jump forward at least
3 inches with both
feet leaving the
ground at the same
time?
6. Does your child
walk up stairs, using
only one foot on each
stair? (The left foot is
on one step, and the
right foot is on the
next.) She may hold
onto the railing or
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 106 of 139
wall.
FINE MOTOR
YES
1. Does your child
use a turning motion
with her hand while
trying to turn
doorknobs, wind up
toys, twist tops, or
screw lids on and off
jars?
2. Does your child flip
switches off and on?
3. After your child
watches you draw a
line from the top of
the paper to the
bottom with a pencil,
crayon, or pen, ask
him to make a line
like yours. Do not let
your child trace your
line. Does your child
copy you by drawing
a single line in a
vertical direction?
4. Does your child
stack seven small
blocks or toys on top
of each other by
herself? (You could
also use spools of
thread, small boxes,
or toys that are about
1 inch in size.)
5. Can your child
string small items
such as beads,
macaroni, or pasta
"wagon wheels" onto
a string or shoelace?
6. After your child
watches you draw a
line from one side of
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 107 of 139
the paper to the other
side, ask her to make
a line like yours. Do
not let your child
trace your line. Does
your child copy you
by drawing a single
line in a horizontal
direction?
PROBLEM SOLVING
YES
1. Does your child
pretend objects are
something else? For
example, does your
child hold a cup to
his ear, pretending it
is a telephone?
Does he put a box on
his head, pretending
it is a hat? Does he
use a block or small
toy to stir food?
2. Does your child
put things away
where they belong?
For example, does
she know her toys
belong on the toy
shelf, her blanket
goes on her bed, and
dishes go in the
kitchen?
3. When looking in
the mirror, ask
"Where is
_________?" (Use
your child's name.)
Does your child point
to his image in the
mirror?
4. If your child wants
something she
cannot reach, does
she find a chair or
box to stand on to
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 108 of 139
reach it (for example,
to get a toy on a
counter or to "help"
you in the kitchen)?
5. While your child
watches, line up four
objects like blocks or
cars in a row. Does
your child copy or
imitate you and line
up four objects in a
row? (You can also
use spools of thread,
small boxes, or other
toys.)
6. When you point to
the figure and ask
your child, "What is
this?" does your child
say a word that
means a person or
something similar?
(Mark "YES" for
responses like
"snowman," "boy,"
"man," "girl,"
"Daddy,"
"spaceman," and
"monkey.")
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
1. If you do any of
the following
gestures, does your
child copy at least
one of them?
a. "Open and close
your mouth."
b. "Blink your eyes."
c. "Pull on your
earlobe."
d. "Pat your cheek."
2. Does your child
eat with a fork?
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 109 of 139
3. When playing with
either a stuffed
animal or a doll, does
your child pretend to
rock it, feed it,
change its diapers,
put it to bed, and so
forth?
4. Does your child
push a little wagon,
stroller, or other toy
on wheels, steering it
around objects and
backing out of
corners if he cannot
turn?
5. Does your child
call herself "I" or "me"
more often than her
own name? For
example, "I do it"
more often than
"Juanita do it."
6. Does your child
put on a coat, jacket,
or shirt by himself?
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers her age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes (1)
o No (2) ________________________________________________
Page 110 of 139
4. Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain.
o Yes
o No ________________________________________________
5. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
6. Do you have concerns about your child's vision? If yes, explain.
o Yes ________________________________________________
o No
7. Has your child had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
8. Do you have any concerns about your child's behavior? If yes, explain.
o Yes ________________________________________________
o No
9. Does anything about your child worry you? If yes, explain.
o Yes________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
Page 111 of 139
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify):________________________________________________
Page 112 of 139
ASQ-3 30-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
COMMUNICATION
YES
1. If you point to a
picture of a ball (kitty,
cup, hat, etc.) and
ask your child, "What
is this?" does your
child correctly name
at least one picture?
o
SOMETIMES
o
NOT YET
o
Page 113 of 139
2. Without your
giving him clues by
pointing or using
gestures, can your
child carry out at
least three of these
kinds of directions?
a. "Put the toy on the
table."
b. "Close the door."
c. "Bring me a towel."
d. "Find your coat."
e. "Take my hand."
f. "Get your book."
3.When you ask your
child to point to her
nose, eyes, hair, feet,
ears, and so forth,
does she correctly
point to at least
seven body parts?
(She can point to
parts of herself, you,
or a doll. Mark
"SOMETIMES" if she
correctly points to at
least three different
body parts.)
4. Does your child
make sentences that
are three or four
words long?
5. Without giving
your child help by
pointing or using
gestures, ask him to
"put the book on the
table" and "put the
shoe under the
chair." Does your
child carry out both of
these directions
correctly?
6. When looking at a
picture book, does
your child tell you
what is happening or
what action is taking
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 114 of 139
place in the picture
(for example,
"barking," "running,"
"eating," or "crying")?
You may ask, "What
is the dog (or boy)
doing?"
GROSS MOTOR
YES
1. Does your child
run fairly well,
stopping herself
without bumping into
things or falling?
2. Does your child
walk either up or
down at least two
steps by himself? He
may hold onto the
railing or wall. (You
can look for this at a
store, on a
playground, or at
home.)
3. Without holding
onto anything for
support, does your
child kick a ball by
swinging his leg
forward?
4. Does your child
jump with both feet
leaving the floor at
the same time?
5. Does your child
walk up stairs, using
only one foot on each
stair? (The left foot is
on one step, and the
right foot is on the
next.) She may hold
onto the railing or
wall.
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 115 of 139
6. Does your child
stand on one foot for
about 1 second
without holding onto
anything?
o
o
o
FINE MOTOR
YES
1. Does your child
use a turning motion
with her hand while
trying to turn
doorknobs, wind up
toys, twist tops, or
screw lids on and off
jars?
2. After your child
watches you draw a
line from the top of
the paper to the
bottom with a pencil,
crayon, or pen, ask
him to make a line
like yours. Do not let
your child trace your
line. Does your child
copy you by drawing
a single line in a
vertical direction?
3. Can your child
string small items
such as beads,
macaroni, or pasta
"wagon wheels" onto
a string or shoelace?
4. After your child
watches you draw a
line from one side of
the paper to the other
side, ask her to make
a line like yours. Do
not let your child
trace your line. Does
your child copy you
by drawing a single
line in a horizontal
direction?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 116 of 139
5. After your child
watches you draw a
single circle, ask him
to make a circle like
yours. Do not let him
trace your
circle. Does your
child copy you by
drawing a circle?
6. Does your child
turn pages in a book,
one page at a time?
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. When looking in the
mirror, ask, "Where is
__________?" (Use
your child's name.)
Does your child point
to her image in the
mirror?
SOMETIMES
NOT YET
o
o
o
2. If your child wants
something he cannot
reach, does he find a
chair or box to stand
on to reach it (for
example, to get a toy
on a counter or to
"help" you in the
kitchen)?
o
o
o
3. While your child
watches, line up four
objects like blocks or
cars in a row. Does
your child copy or
imitate you and line
up four objects in a
row? (You can also
use spools of thread,
small boxes, or other
toys.)
o
o
o
o
o
o
4. When you point to
the figure and ask
your child, "What is
Page 117 of 139
this?" does your child
say a word that
means a person or
something similar?
(Mark "YES" for
responses like
"snowman," "boy,"
"man," "girl," "Daddy,"
"spaceman," and
"monkey.")
5. When you say,
"Say 'seven three,'"
does your child repeat
just the two numbers
in the same order?
Do not repeat the
numbers. If
necessary, try another
pair of numbers and
say, "Say 'eight two.'"
Your child must
repeat just one series
of two numbers for
you to answer "YES"
to this question.
6. After your child
draws a "picture,"
even a simple
scribble, does she tell
you what she drew?
(You may say, "Tell
me about your
picture," or ask, "What
is this?" to prompt
her.)
o
o
o
o
o
o
PERSONAL-SOCIAL
YES
1. If you do any of the
following gestures,
does your child copy
at least one of them?
a. "Open and close
your mouth."
b. "Blink your eyes."
c. "Pull on your
earlobe."
d. "Pat your cheek."
o
SOMETIMES
o
NOT YET
o
Page 118 of 139
2. Does your child
use a spoon to feed
himself with little
spilling?
3. Does your child
push a little wagon,
stroller, or other toy
on wheels, steering it
around objects and
backing out of
corners if she cannot
turn?
4. Does your child
put on a coat, jacket,
or shirt by himself?
5. After you put on
loose-fitting pants
around her feet, does
your child pull them
completely up to her
waist?
6. When your child is
looking in a mirror
and you ask, "Who is
in the mirror?" does
he say either "me" or
his own name?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers her age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
Page 119 of 139
o No ________________________________________________
4. Can other people understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
5. Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain.
o Yes
o No________________________________________________
6. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes ________________________________________________
o No
7. Do you have any concerns about your child's vision? If yes, explain.
o Yes ________________________________________________
o No
8. Has your child had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
o No
9. Do you have any concerns about your child's behavior? If yes, explain.
o Yes ________________________________________________
o No
10. Does anything about your child worry you? If yes, explain.
o Yes ________________________________________________
o No
Page 120 of 139
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 121 of 139
ASQ-3 33-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
COMMUNICATION
YES
1. When you ask
your child to point to
his nose, eyes, hair,
feet, ears, and so
forth, does he
correctly point to at
least seven body
parts? (He can point
to parts of himself,
o
SOMETIMES
o
NOT YET
o
Page 122 of 139
you, or a doll. Mark
"SOMETIMES" if he
correctly points to at
least three different
body parts.)
2. Does your child
make sentences that
are three or four
words long?
3. Without giving
your child help by
pointing or using
gestures, ask her to
"put the book on the
table" and "put the
shoe under the
chair." Does your
child carry out both of
these directions
correctly?
4. When looking at a
picture book, does
your child tell you
what is happening or
what action is taking
place in the picture
(for example,
"barking," "running,"
"eating," or "crying").
You may ask, "What
is the dog (or boy)
doing?"
5. Show your child
how a zipper on a
coat moves up and
down, and say, "See,
this goes up and
down." Put the
zipper to the middle,
and ask your child to
move the zipper
down. Return the
zipper to the middle,
and ask your child to
move the zipper up.
Do this several times,
placing the zipper in
the middle before
o
o
o
o
o
o
o
o
o
o
o
o
Page 123 of 139
asking your child to
move it up or down.
Does your child
consistently move
the zipper up when
you say "up" and
down when you say
"down"?
6. When you ask,
"What is your
name?" does your
child say his first
name or nickname?
o
o
o
GROSS MOTOR
YES
1. Does your child run
fairly well, stopping
herself without
bumping into things
or falling?
2. Without holding
onto anything for
support, does your
child kick a ball by
swinging his leg
forward?
3. Does your child
jump with both feet
leaving the floor at
the same time?
4. Does your child
walk up stairs, using
only one foot on each
stair? (The left foot is
on one step, and the
right foot is on the
next.) She may hold
onto the railing or
wall. (You can look
for this at a store, on
a playground, or at
home.)
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 124 of 139
5. Does your child
stand on one foot for
about 1 second
without holding onto
anything?
(W1_pr_as33g_5)
6. While standing,
does your child throw
a ball overhand by
raising his arm to
shoulder height and
throwing the ball
forward? (Dropping
the ball or throwing
the ball underhand
should be scored as
"NOT YET.")
o
o
o
o
o
o
FINE MOTOR
YES
1. After your child
watches you draw a
line from the top of the
paper to the bottom
with a pencil, crayon,
or pen, ask her to
make a line like
yours. Do not let your
child trace your
line. Does your child
copy you by drawing a
single line in a vertical
direction?
SOMETIMES
NOT YET
o
o
o
2. Can your child
string small items
such as beads,
macaroni, or pasta
"wagon wheels" onto
a string or shoelace?
o
o
o
3. After your child
watches you draw a
line from one side of
the paper to the other
side, ask him to make
a line like yours. Do
not let your child trace
your line. Does your
o
o
o
Page 125 of 139
child copy you by
drawing a single line
in a horizontal
direction?
4. After your child
watches you draw a
single circle, ask her
to make a circle like
yours. Do not let her
trace your
circle. Does your
child copy you by
drawing a circle?
o
o
o
5. Does your child
turn pages in a book,
one page at a time?
o
o
o
6. Does your child try
to cut paper with
child-safe scissors?
He does not need to
cut the paper but must
get the blades to open
and close while
holding the paper with
the other hand. (You
may show your child
how to use scissors.
Carefully watch your
child's use of scissors
for safety reasons.)
o
o
o
PROBLEM SOLVING
YES
1. When looking in the
mirror, ask, "Where is
_______?" (Use your
child's name.) Does
your child point to her
image in the mirror?
2. While your child
watches, line up four
objects like blocks or
cars in a row. Does
your child copy or
imitate you and line
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 126 of 139
up four objects in a
row? (You can also
use spools of thread,
small boxes, or other
toys.)
3. If your child wants
something he cannot
reach, does he find a
chair or box to stand
on to reach it (for
example, to get a toy
on a counter or to
"help" you in the
kitchen)?
4. When you point to
the figure and ask
your child, "What is
this?" does your child
say a word that
means a person or
something similar?
(Mark "YES" for
responses like
"snowman," "boy,"
"man," "girl," "Daddy,"
"spaceman," and
"monkey.")
5. When you say,
"Say 'seven three,'"
does your child repeat
just the two numbers
in the same order?
Do not repeat the
numbers. If
necessary, try another
pair of numbers and
say, "Say 'eight two.'"
(Your child must
repeat just one series
of two numbers for
you to answer "YES"
to this question.)
6. After your child
draws a "picture,"
even a simple
scribble, does she tell
you what she drew?
(You may say, "Tell
o
o
o
o
o
o
o
o
o
o
o
o
Page 127 of 139
me about your
picture," or ask, "What
is this?" to prompt
her.)
PERSONAL-SOCIAL
YES
1. Does your child
use a spoon to feed
herself with little
spilling?
2. Does your child
push a little wagon,
stroller, or other toy
on wheels, steering it
around objects and
backing out of
corners if he cannot
turn?
3. Does your child
put on a coat, jacket,
or shirt by herself?
4. After you put on
loose-fitting pants
around his feet, does
your child pull them
completely up to his
waist?
5. When your child is
looking in a mirror
and you ask, "Who is
in the mirror?" does
she say either "me"
or her own name?
6. Using these exact
words, ask your child,
"Are you a girl or a
boy?" Does your
child answer
correctly?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
Page 128 of 139
o Yes
o No ________________________________________________
2. Do you think your child talks like other toddlers her age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
o No________________________________________________
4. Can other people understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
5. Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain.
o Yes
o No ________________________________________________
6. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes________________________________________________
o No
7. Do you have any concerns about your child's vision? If yes, explain.
o Yes________________________________________________
o No
8. Has your child had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
Page 129 of 139
o No
9. Do you have any concerns about your child's behavior? If yes, explain.
o Yes ________________________________________________
o No
10. Does anything about your child worry you? If yes, explain.
o Yes ________________________________________________
o No
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 130 of 139
ASQ-3 36-Month Version
Please provide the following information.
Date ASQ completed (MM/DD/YYYY):
________________________________________________
Child's date of birth (MM/DD/YYYY):
________________________________________________
Child's sex
o Male
o Female
Does the child have a diagnosed disability or special need (e.g., autism, speech delay)?
If yes, please specify.
o Yes ________________________________________________
o No
On the following pages are questions about activities children may do. Your child may have
already done some of the activities described here, and there may be some your child has not
begun doing yet. For each item, please click in the circle that indicates whether your child is
doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
• Try each activity with your child before marking a response.
• Make completing this questionnaire a game that is fun for you and your child.
• Make sure your child is rested and fed.
COMMUNICATION
YES
1. When you ask your
child to point to her
nose, eyes, hair, feet,
ears, and so forth,
does she correctly
point to at least seven
body parts? (She can
point to parts of
o
SOMETIMES
o
NOT YET
o
Page 131 of 139
herself, you, or a doll.
Mark "sometimes" if
she correctly points to
at least three different
body parts.)
2. Does your child
make sentences that
are three or four
words long?
3. Without giving your
child help by pointing
or using gestures, ask
him to "put the book
on the table" and "put
the shoe under the
chair." Does your
child carry out both of
these directions
correctly?
4. When looking at a
picture book, does
your child tell you
what is happening or
what action is taking
place in the picture
(for example,
"barking," "running,"
"eating," or "crying")?
You may ask, "What
is the dog (or boy)
doing?"
5. Show your child
how a zipper on a
coat moves up and
down, and say, "See,
this goes up and
down." Put the zipper
to the middle and ask
your child to move the
zipper down. Return
the zipper to the
middle and ask your
child to move the
zipper up. Do this
several times, placing
the zipper in the
middle before asking
your child to move it
o
o
o
o
o
o
o
o
o
o
o
o
Page 132 of 139
up or down. Does
your child consistently
move the zipper up
when you say "up"
and down when you
say "down"?
6. When you ask,
"What is your name?"
does your child say
both her first and last
names?
o
o
o
GROSS MOTOR
YES
1. Without holding
onto anything for
support, does your
child kick a ball by
swinging his leg
forward?
2. Does your child
jump with both feet
leaving the floor at the
same time?
3. Does your child
walk up stairs, using
only one foot on each
stair? (The left foot is
on one step, and the
right foot is on the
next.) She may hold
onto the railing or
wall. (You can look
for this at a store, on a
playground, or at
home.)
4. Does your child
stand on one foot for
about 1 second
without holding onto
anything?
5. While standing,
does your child throw
a ball overhand by
raising his arm to
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Page 133 of 139
shoulder height and
throwing the ball
forward? (Dropping
the ball or throwing
the ball underhand
should be scored as
"NOT YET.")
6. Does your child
jump forward at least
6 inches with both feet
leaving the ground at
the same time?
o
o
o
FINE MOTOR
YES
1. After your child
watches you draw a
line from the top of the
paper to the bottom
with a pencil, crayon,
or pen, ask her to
make a line like
yours. Do not let your
child trace your
line. Does your child
copy you by drawing a
single line in a vertical
direction?
2. Can your child
string small items
such as beads,
macaroni, or pasta
"wagon wheels" onto
a string or shoelace?
3. After your child
watches you draw a
single circle, ask him
to make a circle like
yours. Do not let him
trace your
circle. Does your
child copy you by
drawing a circle?
4. After your child
watches you draw a
line from one side of
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
Page 134 of 139
the paper to the other
side, ask her to make
a line like yours. Do
not let your child trace
your line. Does your
child copy you by
drawing a single line
in a horizontal
direction?
5. Does your child try
to cut paper with
child-safe scissors?
He does not need to
cut the paper but must
get the blades to open
and close while
holding the paper with
the other hand. (You
may show your child
how to use scissors.
Carefully watch your
child's use of scissors
for safety reasons.)
6. When drawing,
does your child hold a
pencil, crayon, or pen
between her fingers
and thumb like an
adult does?
o
o
o
o
o
o
PROBLEM SOLVING
YES
1. While your child
watches, line up four
objects like blocks or
cars in a row. Does
your child copy or
imitate you and line
up four objects in a
row? (You can also
use spools of thread,
small boxes, or other
toys.)
2. If your child wants
something he cannot
reach, does he find a
SOMETIMES
NOT YET
o
o
o
o
o
o
Page 135 of 139
chair or box to stand
on to reach it (for
example, to get a toy
on a counter or to
"help" you in the
kitchen)?
3. When you point to
the figure and ask
your child, "What is
this?" does your child
say a word that
means a person or
something similar?
(Mark "yes" for
responses like
"snowman," "boy,"
"man," "girl," "Daddy,"
"spaceman," and
"monkey.")
4. When you say,
"Say 'seven three,'"
does your child repeat
just the two numbers
in the same order?
Do not repeat the
numbers. If
necessary, try another
pair of numbers and
say, "Say 'eight two.'"
(Your child must
repeat just one series
of two numbers for
you to answer "YES"
to this question.)
5. Show your child
how to make a bridge
with blocks, boxes, or
cans, like the
example. Does your
child copy you by
making one like it?
6. When you say,
"Say 'five eight three,'"
does your child repeat
just the three numbers
in the same order?
Do not repeat the
numbers. If
o
o
o
o
o
o
o
o
o
o
o
o
Page 136 of 139
necessary, try another
series of numbers and
say, "Say 'six nine
two.'" (Your child must
repeat just one series
of three numbers for
you to answer "YES"
to this question.)
PERSONAL-SOCIAL
YES
1. Does your child use
a spoon to feed
herself with little
spilling?
2. Does your child
push a little wagon,
stroller, or toy on
wheels, steering it
around objects and
backing out of corners
if he cannot turn?
3. When your child is
looking in a mirror and
you ask, "Who is in
the mirror?" does she
say either "me" or her
own name?
4. Does your child put
on a coat, jacket, or
shirt by himself?
5. Using these exact
words, ask your child,
"Are you a girl or a
boy?" Does your child
answer correctly?
6. Does your child
take turns by waiting
while another child or
adult takes a turn?
SOMETIMES
NOT YET
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
OVERALL
1. Do you think your child hears well? If no, explain.
Page 137 of 139
o Yes
o No________________________________________________
2. Do you think your child talks like other children her age? If no, explain.
o Yes
o No ________________________________________________
3. Can you understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
4. Can other people understand most of what your child says? If no, explain.
o Yes
o No ________________________________________________
5. Do you think your child walks, runs, and climbs like other children his age? If no explain.
o Yes
o No________________________________________________
6. Does either parent have a family history of childhood deafness or hearing impairment? If yes,
explain.
o Yes________________________________________________
o No
7. Do you have any concerns about your child's vision? If yes, explain.
o Yes ________________________________________________
o No
8. Has your child had any medical problems in the last several months? If yes, explain.
o Yes ________________________________________________
Page 138 of 139
o No
9. Do you have any concerns about your child's behavior? If yes, explain.
o Yes (1) ________________________________________________
o No (2)
10. Does anything about your child worry you? If yes, explain.
o Yes (1) ________________________________________________
o No (2)
Follow-up action taken (check all that apply):
▢
Provide activities and rescreen in _____ months (specify number of months until
rescreen):________________________________________________
▢
▢
▢
▢
▢
Share results with primary health care provider.
Refer for hearing screening.
Refer for vision screening.
Refer for 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.
Other (specify): ________________________________________________
Page 139 of 139
| File Type | application/pdf |
| File Title | Microsoft Word - ASQ-3.docx |
| File Modified | 2022-05-03 |
| File Created | 2022-04-28 |