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
Jane hides her shoes for Maria to find.
Al read the blue book under his bed.
Please write your child's responses below:
(Mark "yes" if he finishes three of four sentences correctly. Mark "sometimes" if he finishes two of four sentences correctly.)
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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