ASQ 18th Month Questionnaire

Date ASQ completed

Child's information

Child's first name:

Middle initial

Child's last name

Child's date of birth

If child was born 3 or more weeks prematurely, # of weeks premature:

Child's gender

Male Female

Person filling out questionnaire

First name

Middle initial

Last name

Street address

City

State/Province

ZIP/Postal code

Country

Home telephone number

Other telephone number

Relationship to child

Parent Guardian Teacher Child care Provider Grandparent or other relative Foster parent other

If other, please specify.

Email address

Names of people assisting in questionnaire completion

PROGRAM INFORMATION

Child ID #

Age at administration, in months and days

Program ID #

If premature, adjusted age, in months and days

Program name

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 fill 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.
Please return this questionnaire by

Notes

COMMUNICATION

1. When your child wants something, does she tell you by pointing to it?

Yes Sometimes Not Yet

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.")

Yes Sometimes Not Yet

3. Does your child say eight or more words in addition to "Mama" and "Dada"?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

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 "byebye," "all gone," "all right," and "What's that?") Please give an example of your child's word combinations:

Yes Sometimes Not Yet

COMMUNICATION TOTAL

GROSS MOTOR

1. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?

Yes Sometimes Not Yet

2. Does your child move around by walking, rather than by crawling on her hands and knees?

Yes Sometimes Not Yet

3. Does your child walk well and seldom fall?

Yes Sometimes Not Yet

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)?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

6. 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? (Ifyour child already kicks a ball, mark "yes" for this item.)

Yes Sometimes Not Yet

GROSS MOTOR TOTAL

FINE MOTOR

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.)

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

3. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?

Yes Sometimes Not Yet

4. Does your child stack three small blocks or toys on top of each other by himself?

Yes Sometimes Not Yet

5. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)

Yes Sometimes Not Yet

6. Does your child get a spoon into her mouth right side up so that the food usually doesn't spill?

Yes Sometimes Not Yet

FINE MOTOR TOTAL

PROBLEM SOLVING

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.)

Yes Sometimes Not Yet

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?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

4. Without your showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)?

Yes Sometimes Not Yet

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" ifyour child scribbles back and forth.)

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

PROBLEM SOLVING TOTAL

*tf Problem Solving item 6 is marked "yes" or "sometimes," mark Problem Solving Item 3 "yes".

PERSONAL-SOCIAL

1. While looking at herself in the mirror, does your child offer a toy to her own image?

Yes Sometimes Not Yet

2. Does your child play with a doll or stuffed animal by hugging it?

Yes Sometimes Not Yet

3. Does your child get your attention or try to show you something by pulling on your hand or clothes?

Yes Sometimes Not Yet

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?

Yes Sometimes Not Yet

5. Does your child drink from a cup or glass, putting it down again with little spilling?

Yes Sometimes Not Yet

6. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?

Yes Sometimes Not Yet

PERSONAL-SOCIAL TOTAL

OVERALL

Parents and providers may use the space below for additional comments.

1. Do you think your child hears well? If no, explain:

Yes No

2. Do you think your child talks like other toddlers his age? If no, explain:

Yes No

3. Can you understand most of what your child says? If no, explain:

Yes No

4. Do you think your child walks, runs, and climbs like other toddlers her age? If no, explain:

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

6 Month ASQ-3 Information Summary

Child's name

Date ASQ completed

Child's ID #

Date of Birth

Administering program/provider

Was age adjusted for prematurity when selecting questionnaire?

Yes No

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

AREA

CUT-OFF

TOTAL SCORE

Communication

13.06

Gross Motor

37.38

Fine Motor

34.32

Problem Solving

25.74

Personal-Social

27.19

2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6.

1. Hears well?

Yes NO

Comments

2. Talks like other toddlers his age?

Yes NO

Comments

3. Understand most of what your child says?

Yes NO

Comments

4. Walks, runs, and climbs like other toddlers?

Yes NO

Comments

5. Family history of hearing impairment?

YES No

Comments

6. Concerns about vision?

YES No

Comments

7. Any medical problems?

YES No

Comments

8. Concerns about behavior?

YES No

Comments

8. Other concerns?

YES No

Comments

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

Provide activities and rescreen in __ months

Share results with primary health care provider.

Refer for (circle all that apply) hearing, vision, and/or behavioral screening.

Refer to primary health care provider or other community agency (specify reason)

Refer to early intervention/early childhood special education

No further action taken at this time

Other (specify)

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

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

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