Ages & Stages Questionnaire for 9 Month Old

9 Month ASQ-3 Ages and Stages Questionnaires

9 months 0 days through 9 months 30 days
9 Month Questionnaire

Please provide the following information.

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:

Relationship to baby:

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

If other, specify:

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

Baby ID #:

Age at administration in months and days:

Program ID #:

If premature, adjusted age in months and days:

Program name:

9 Month Questionnaire

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

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

Notes:

COMMUNICATION

1. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?

Yes Sometimes Not Yet

Score:

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

Yes Sometimes Not Yet

Score:

3. Does your baby make two similar sounds like “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)

Yes Sometimes Not Yet

Score:

4. If you ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself (such as “bye-bye,” “Peeka-boo,” “clap your hands,” “Pat-a-cake”)?

Yes Sometimes Not Yet

Score:

5. Without showing her what you mean, does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back”?

Yes Sometimes Not Yet

Score:

6. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)

Yes Sometimes Not Yet

Score:

COMMUNICATION TOTAL:

GROSS MOTOR

1. If you hold both hands just to balance your baby, does she support her own weight while standing?

Yes Sometimes Not Yet

Score:

2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?

Yes Sometimes Not Yet

Score:

3. When you stand your baby next to furniture or the cot rail, does she hold on without leaning her chest against the furni- ture for support?

Yes Sometimes Not Yet

Score:

4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?

Yes Sometimes Not Yet

Score:

5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?

Yes Sometimes Not Yet

Score:

6. Does your baby walk beside furniture while holding on with only one hand?

Yes Sometimes Not Yet

Score:

GROSS MOTOR TOTAL:

FINE MOTOR

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

Yes Sometimes Not Yet

Score:

2. Does your baby successfully pick up a small cube of bread by using her thumb and all of her fingers in a raking motion? (If she already picks up a small cube of bread, mark “yes” for this item.)

Yes Sometimes Not Yet

Score:

3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)

Yes Sometimes Not Yet

Score:

4. After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (The string may be attached to a toy.)

Yes Sometimes Not Yet

Score:

5. Does your baby pick up a small cube of bread with the tips of his thumb and a finger? (He may rest his arm or hand on the table while doing it.)

Yes Sometimes Not Yet

Score:

* If Fine Motor Item 5 is marked “yes” or “sometimes,” mark Fine Motor Item 2 “yes.”

6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?

Yes Sometimes Not Yet

Score:

FINE MOTOR TOTAL:

PROBLEM SOLVING

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

Yes Sometimes Not Yet

Score:

2. Does your baby pick up two small toys, one in each hand, and hold on to them for about 1 minute?

Yes Sometimes Not Yet

Score:

3. When holding a toy in his hand, does your baby bang it against another toy on the table?

Yes Sometimes Not Yet

Score:

4. While holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?

Yes Sometimes Not Yet

Score:

5. Does your baby poke at or try to get a raisin that is inside a clear plastic bottle (such as a small water bottle or baby bottle)?

Yes Sometimes Not Yet

Score:

6. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.)

Yes Sometimes Not Yet

Score:

PROBLEM SOLVING TOTAL:

PERSONAL-SOCIAL

1. While your baby is on her back, does she put her foot in her mouth?

Yes Sometimes Not Yet

Score:

2. Does your baby drink water, juice, or formula from a cup while you hold it?

Yes Sometimes Not Yet

Score:

3. Does your baby feed himself finger foods such as a cracker, a chapati, or a biscuit?

Yes Sometimes Not Yet

Score:

4. When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn’t let go of it? (If she already lets go of the toy into your hand, mark “yes” for this item.)

Yes Sometimes Not Yet

Score:

5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?

Yes Sometimes Not Yet

Score:

6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?

Yes Sometimes Not Yet

Score:

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?

Yes No

If no, explain:

2. When you help your baby stand, are his feet flat on the surface most of the time?

Yes No

If no, explain:

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

Yes No

If yes, explain:

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

Yes No

If yes, explain:

5. Do you have concerns about your baby’s eyesight?

Yes No

If yes, explain:

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

Yes No

If yes, explain:

7. Do you have any concerns about your baby’s behaviour?

Yes No

If yes, explain:

8. Does anything about your baby worry you?

Yes No

If yes, explain:

Your information will be encrypted.