ASQ 24 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 #

Program ID #

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. 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?" (She needs to identify only one picture correctly.)

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

3. Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?

Yes Sometimes Not Yet

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?

Yes Sometimes Not Yet

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 combinations that express one idea, such as "byebye," "alt gone," "all right," and "What's that?") Please give an example of your child's word combinations:

Yes Sometimes Not Yet

6. Does your child correctly use at least two words like "me," "I," "mine," and "you"?

Yes Sometimes Not Yet

COMMUNICATION TOTAL

GROSS MOTOR

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.)

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

3. Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wall.

Yes Sometimes Not Yet

4. Does your child run fairly well, stopping herself without bumping into things or falling?

Yes Sometimes Not Yet

5. Does your child jump with both feet leaving the floor at the same time?

Yes Sometimes Not Yet

6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?

Yes Sometimes Not Yet

GROSS MOTOR TOTAL

"If Cross Motor item 6 is marked "yes" or "sometimes," mark Gross Motor Item 2 "yes."

FINE MOTOR

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

Yes Sometimes Not Yet

2. Does your child turn the pages of a book by herself? (She may turn more than one page at a time.)

Yes Sometimes Not Yet

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?

Yes Sometimes Not Yet

4. Does your child flip switches off and on?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

6. Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace?

Yes Sometimes Not Yet

FINE MOTOR TOTAL

PROBLEM SOLVING

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.)

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

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?

Yes Sometimes Not Yet

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?

Yes Sometimes Not Yet

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 to "help" you in the kitchen)?

Yes Sometimes Not Yet

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 i— can also use spools ofthread, small boxes, or other toys.)

Yes Sometimes Not Yet

PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL

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

Yes Sometimes Not Yet

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

Yes Sometimes Not Yet

3. Does your child eat with a fork?

Yes Sometimes Not Yet

4. 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?

Yes Sometimes Not Yet

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?

Yes Sometimes Not Yet

6. Does your child call herself "1" or "me" more often than her own name? For example, "1 do it," more often than "Juanita do it."

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 her 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 his 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

25.17

Gross Motor

38.07

Fine Motor

35.16

Problem Solving

29.78

Personal-Social

31.54

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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