Ages & Stages Questionnaire for 24 Month Old

Northwest Suburban Pediatrics

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24 Month ASQ-3 Ages and Stages Questionnaires

23 months 0 days through 25 months 15 days

Please provide the following information. Use black or blue ink only and print legibly when completing this form.

Child's information

Person filling out questionnaire

Program Information

24 Month Questionnaire

23 months 0 days through 25 months 15 days

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, 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 rested and fed.

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

GROSS MOTOR

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

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL

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

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