24 MONTH/2 YEAR ASQ: SE QUESTIONNAIRE

Please provide the following information.

Child's Name

Child's Date of Birth:

Today's Date:

Person filling out this questionnaire:

What is your relationship to the child?

Your telephone:

Your mailing address:

City:

State:

Zip Code:

List people in assisting questionnaire completion:

Administering program or provider:

Please read each question carefully and

1. Check the box that best describes your child's behavior and
2. Check the circle if this behavior is a concern.

1. Does your child look at you when you talk to him?

Most of the time (z)

Sometimes (v)

Rarely or Never (x)

Is this a concern?

Yes No

2. Does your child seem too friendly with strangers?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

3. Does your child smile or laugh when you play with her?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

4. Is your child's body relaxed?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

5. When you leave, does your child remain upset or cry for more than an hour?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

6. Does your child greet or say hello to familiar adults?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

7. Does your child liked to be hugged or cuddled?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

8. When upset, does your child calm down within 16 minutes?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

9. Does your child stiffen and arch his back when picked up?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

10. Is your child interested in things around her, such as people, toys, and food?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

11. Does your child cry, scream, or have tantrums for a long period of time?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

12. Do you and your child enjoy mealtimes together?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

13. Does your child have eating problems, such as stuffing, vomiting, eating nonfood items, or (kindly indicate other problems on the space provided below)?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

You may write in other problems.

14. Does your child sleep at least 10 hours within a 24-hour period?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

15. When you point at something, does your child look in the direction you are pointing?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

16. Does your child have trouble falling asleep at naptime or at night?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

17. Does your child get constipated or have diarrhea?

Most of the time (x)

Sometimes (v)

Rarely (z)

Is this a concern?

Yes No

18. Does your child follow simple directions? For example, does he sit down when asked?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

19. Does you child let you know what she is feeling with gestures or words? For example, does she let you know when she's feeling hungry, hurt, or tired?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

20. Does your child check to make sure you are near when exploring new places, such as a park or a new friend's home?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

21. Does your child do things over and over and can't seem to stop? Examples are rocking, hand flapping, spinning, or (kindly indicate other problems in the space provided below).

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

You may write in something else.

22. Does your child like to hear stories or sing songs?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

23. Does your child hurt himself on purpose?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

24. Does your child like to be around other children?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

25. Does your child try to hurt other children, adults, or animals (for example, by kicking or biting)?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

26. Has anyone expressed concerns about your child's behaviors.

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

If you checked "sometimes" or "most of the time", please explain.

27. Do you have concerns about your child's eating or sleeping behaviors?

Yes No

If so, please explain.

28. Is there anything else that worries you about your child?

Yes No

If so, please explain.

29. What things do you enjoy most about your child?

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