Answers to ASQ

Patient name

Date of Birth

Name of person completing form

Date completed

COMMUNICATION

Question 1

Yes Sometimes Not yet

Question 2

Yes Sometimes Not yet

Questions 3

Yes Sometimes Not yet

Question 4

Yes Sometime Not yet

Questions 5

Yes Sometimes Not Yet

Question 6

Yes Sometimes Not yet

GROSS MOTOR

Question 1

Yes Sometimes Not Yet

Question 2

Yes Sometimes Not Yet

Question 3

Yes Sometimes Not yet

Question 4

Yes Sometimes Not Yet

Question 5

Yes Sometimes Not yet

Question 6

Yes Sometimes Not Yet

FINE MOTOR

Question 1

Yes Sometimes Not Yet

Question 2

Yes Sometimes Not Yet

Question 3

Yes Sometimes Not Yet

Question 4

Yes Sometimes Not yet

Question 5

Yes Sometimes Not yet

Question 6

Yes Sometimes Not Yet

PROBLEM SOLVING

Question 1

Yes Sometimes Not Yet

Question 2

Yes Sometimes Not Yet

Question 3

Yes Sometimes Not Yet

Question 4

Yes Sometimes Not Yet

Question 5

Yes Sometimes Not Yet

Question 6

Yes Sometimes Not Yet

PERSONAL-SOCIAL

Question 1

Yes Sometimes Not Yet

Question 2

Yes Sometimes Not Yet

Question 3

Yes Sometimes Not Yet

Question 4

Yes Sometimes Not Yet

Question 5

Yes Sometimes Not Yet

Question 6

Yes Sometimes Not Yet

OVERALL

Any Overall Concerns

Yes Not

If yes, please explain

Family history of hearing impairment

Yes No

If yes, please explain

Concerns about vision

Yes No

If yes, please explain

Recent Medical Problems

Yes No

If yes, please explain

Concern about Behavior

Yes No

If yes, please explain

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