Ages & Stages Questionnaire for 18 Month Old

18 Month ASQ-3 Ages and Stages Questionnaires

17 months 0 days through 18 months 30 days
18 Month Questionnaire

Please provide the following information.

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:

Relationship to child:

Parent Grandparent or other relative Guardian Foster parent Teacher Child care provider Other

If other, please specify:

Street address:

City:

State/Province:

ZIP/Postal Code:

Country:

Home telephone number:

Other telephone number:

E-mail 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:

18 Month Questionnaire

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 select the circle that indicates whether your child is doing the activity regularly (yes), sometimes, or not yet.

Important Points to Remember:
1. Try each activity with your child before marking a response.
2. Make completing this questionnaire a game that is fun for you and your child.
3. Make sure your child is not tired or hungry.
4. Please bring this questionnaire with you to your child’s health and development review.

Notes:

At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your child more than one time. If possible, try the activities when your child is cooperative. If your child can do the activity but refuses, mark “yes” for the item.

COMMUNICATION

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

Yes Sometimes Not Yet

Score:

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 and get your blanket.”)

Yes Sometimes Not Yet

Score:

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

Yes Sometimes Not Yet

Score:

4. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as “Mama eat,” “Dada 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

Score:

5. Without showing him, does your child point to the correct picture when you say, “Show me the cat,” or ask, “Where is the dog?” (He needs to identify only one picture correctly.)

Yes Sometimes Not Yet

Score:

6. Does your child say two or three words that represent different ideas together, such as “See dog,” “Mummy come home,” or “Cat gone”? (Don’t count word combinations that express one idea, such as “bye-bye,” “all gone” “all right,” and “What’s that?”)

Yes Sometimes Not Yet

Score:

Please give an example of your child’s word combinations:

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

Score:

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

Yes Sometimes Not Yet

Score:

3. Does your child walk well and seldom fall over?

Yes Sometimes Not Yet

Score:

4. Does your child climb on an object such as a chair to reach something he wants (for example, to reach a toy on a table or worktop or to “help” you in the kitchen)?

Yes Sometimes Not Yet

Score:

5. Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the handrail or wall. (You can look for this in a shop, in a playground, or at home.)

Yes Sometimes Not Yet

Score:

6. When you show your child how to kick a large ball, does he try to kick the ball either 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

Score:

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

Score:

2. Does your child stack a small block or toy on top of another one? (You could also use cotton reels, small boxes, or toys that are about 1 inch in size.)

Yes Sometimes Not Yet

Score:

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

Score:

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

Yes Sometimes Not Yet

Score:

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

Score:

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

Score:

FINE MOTOR TOTAL:

PROBLEM SOLVING

1. Does your child drop several small toys, one after another, into a container like a bowl or a box? (You may show him how to do it.)

Yes Sometimes Not Yet

Score:

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

Score:

3. After a raisin is dropped into a clear plastic bottle, does your child turn the bottle over to tip it out? (You may show him how.) (You can use a small water bottle or baby bottle.)

Yes Sometimes Not Yet

Score:

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

Yes Sometimes Not Yet

Score:

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” if your child scribbles back and forth.)

Yes Sometimes Not Yet

Score:

6. After a raisin is dropped into a clear plastic bottle, does your child turn the bottle upside down to tip out the raisin? (Do not show him how.) (You can use a small water bottle or baby bottle.)

Yes Sometimes Not Yet

Score:

* If Problem Solving Item 6 is marked “yes” or “sometimes,” mark Problem Solving Item 3 “yes.”

PROBLEM SOLVING TOTAL:

PERSONAL-SOCIAL

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

Yes Sometimes Not Yet

Score:

2. Does your child play with a doll or soft toy by hugging it?

Yes Sometimes Not Yet

Score:

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

Yes Sometimes Not Yet

Score:

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

Score:

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

Yes Sometimes Not Yet

Score:

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

Yes Sometimes Not Yet

Score:

PERSONAL-SOCIAL TOTAL:

OVERALL

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

1. Do you think your child hears well?

Yes No

If no, explain:

2. Do you think your child talks like other toddlers his age?

Yes No

If no, explain:

3. Can you understand most of what your child says?

Yes No

If no, explain:

4. Do you think your child walks, runs, and climbs like other toddlers her age?

Yes No

If no, explain:

5. Does either parent have a family history of childhood deafness or hearing problems?

Yes No

If yes, explain:

6. Do you have concerns about your child’s eyesight?

Yes No

If yes, explain:

7. Has your child had any medical or health-related problems in the last few months?

Yes No

If yes, explain:

8. Do you have any concerns about your child’s behavior?

Yes No

If yes, explain:

9. Does anything about your child worry you?

Yes No

If yes, explain:

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