On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
Try each activity with your baby before marking a response.
Make completing this questionnaire a game that is fun for you and your baby.
Make sure your baby is rested and fed.
Please return this questionnaire by
If problem Solving Item 5 is marked "yes" or "sometimes", mark Problem Solving Item 4 "yes".
Parents and providers may use the space below for additional comments.
6 Month ASQ-3 Information Summary
1.SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User’s Guide for details, including how to adjust scores if item responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.
3.ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
4. FOLLOW-UP ACTION TAKEN: Check ail that apply
5. OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X = response missing)
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