ASQ 6 Month Questionnaire

Date ASQ completed

Baby's information

Baby's first name:

Middle initial

Baby's last name

Baby's date of birth

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

Baby'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 baby

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

Baby 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 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

Notes

COMMUNICATION

1. Does your baby make high-pitched squeals?

Yes Sometimes Not Yet

2. When playing with sounds, does your baby make grunting, growling, or other deep-toned sounds?

Yes Sometimes Not Yet

3. If you call your baby when you are out of sight, does she look in the direction of your voice?

Yes Sometimes Not Yet

4. When a loud noise occurs, does your baby turn to see where the sound came from?

Yes Sometimes Not Yet

5. Does your baby make sounds like "da," "ga," "ka," and "ba"?

Yes Sometimes Not Yet

6. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?

Yes Sometimes Not Yet

COMMUNICATION TOTAL

GROSS MOTOR

1. While your baby is on his back, does your baby lift his legs high enough to see his feet?

Yes Sometimes Not Yet

2. When your baby is on her tummy, does she straighten both arms and push her whole chest off the bed or floor?

Yes Sometimes Not Yet

3. Does your baby roll from his back to his tummy, getting both arms out from under him?

Yes Sometimes Not Yet

4. 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.)

Yes Sometimes Not Yet

5. If you hold both hands just to balance your baby, does he support his own weight while standing?

Yes Sometimes Not Yet

6. Does your baby get into a crawling position by getting up on her hands and knees?

Yes Sometimes Not Yet

GROSS MOTOR TOTAL

FINE MOTOR

1. Does your baby grab a toy you offer and look at it, wave it about, or chew on it for about 1 minute?

Yes Sometimes Not Yet

2. Does your baby reach for or grasp a toy using both hands at once?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

4. Does your baby pick up a small toy, holding it in the center of her hand with her fingers around it?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

6. Does your baby pick up a small toy with only one hand?

Yes Sometimes Not Yet

FINE MOTOR TOTAL

PROBLEM SOLVING

1. When a toy is in front of your baby, does she reach for it with both hands?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

3. When your baby is on her back, does she try to get a toy she has dropped if she can see it?

Yes Sometimes Not Yet

4. Does your baby pick up a toy and put it in his mouth?

Yes Sometimes Not Yet

5. Does your baby pass a toy back and forth from one hand to the other?

Yes Sometimes Not Yet

6. Does your baby play by banging a toy up and down on the floor or table?

Yes Sometimes Not Yet

PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL

1. When in front of a large mirror, does your baby smile or coo at herself?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

3. While lying on her back, does your baby play by grabbing her foot?

Yes Sometimes Not Yet

4. When in front of a large mirror, does your baby reach out to pat the mirror?

Yes Sometimes Not Yet

5. While your baby is on his back, does he put his foot in his mouth?

Yes Sometimes Not Yet

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.)

Yes Sometimes Not Yet

PERSONAL-SOCIAL TOTAL

OVERALL

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

1. Does your baby use both hands and both legs equally well? If no, explain:

Yes No

2. When you help your baby stand, are his feet flat on the surface most of the time? If no, explain:

Yes No

3. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

8. Does anything about your baby worry you? If yes, explain:

Yes No

6 Month ASQ-3 Information Summary

Baby's name

Date ASQ completed

Baby's ID #

Dateof 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

29.65

Gross Motor

22.5

Fine Motor

25.14

Problem Solving

27.72

Personal-Social

25.34

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

1. Uses both hands and both legs equally well?

Yes NO

Comments

2. Feet are flat on the surface most of the time?

Yes NO

Comments

3. Concerns about not making sounds?

YES No

Comments

4. Family history of hearing impairment?

YES No

Comments

5. Concerns about vision?

YES No

Comments

6. Any medical problems?

YES No

Comments

7. 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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