~~ RASQD Ages & Stages Questionnaires® 15 month 0 day trough 16 month 30 dys 1 6 month Questionnaire Peep ein ems ind thant vermont. OE o3/ 1D Child's information mine DACL- we Cy cuttunm Cvtiem Fatoctie Fehon bom agar Seam a cunsnune OZ-/O \ eit eee /A sO fe Person filing out questionnaire Petree Kal lnbee har / Lest name Van Yes S4y O curios Oyen, © S84 sestaees: ge OR Com ow Fee Fob code: com ibe Seba ee ane BMameri tech net Names of peopl siting n questions conplaten Program Information uae age et achiniation a month and ds Progam premature aj ge months and dys ase meee P101160100 ae ge te niSekagee Ngee(AASQ?) ‘whether your child is doing the activity regulary, sometimes, or not yet Important Points to Remember: Notes: -Tryeach activ wth your child before making a response ‘Make completing this questionnaire a game that i fun for you and your chil g ‘BH Make sure your child is rested and fed. a Please return this questionnaire by _____ 16 Month Questionnaire On the following pages are questions about activities children may do. Your child may have Goecrbed hore, and there mey be some your child has not begun doing yet. For eech iter, 15 months 0 days through 16 months 30 days aleady done some of the activities please fil n the circle that indicates [at this oge, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with Your ive. if your child can do the activity but refuses, ‘child more than one time. If possible, try the activities when your child is cooperati ‘mark "yes" forthe iter. COMMUNICATION 1. Does your child point to, pat, or try to pick up pletures in a book? 2. Does "Dada"? 1 child say four or more words in addition to "Mama" and 3. When your child wants something, does she tell you by pointing to ie? ae ‘When you ask your child to, does he go into another room to find a fa rriliar toy or object? (You might ask, "Where is your ball?” or say, "Bring me your coat," or “Go get your bianket.”) 5, Does your child imitate a two-word sentence? For example, when you say 2 two-word phrase, such as "Mame eat," “Daddy play," “Go home,” or "What's this?” does your child say both words back to you? (ark "yes" even if her words are dificult to understand) 6, Does your child say eight or more words in adcition to “Mama” and "Dada"? GROSS MOTOR 1. Does your child stand up in the middle of the floor by himself and take several steps forward? 2. Does your child climbs onto furnit large climbing blocks? 1 or other large objects, such as, 3. Does your child bend over oF squat to pick up an object from the floor and then stand up again without any support? vs ye ° o oO ° oO ves oO Q0 wuenes One ° ° ° eo “0 ° ow o ° dS Oo oS COMMUNICATION TOTA sowenmes —_NOTYET ° oS ° ° er =O 101160200 I te eate Aieraned iS lolo Ne wil? | | IS jo page 201516 Month Questionnaire pose 30f6 ROSS MOTOR tcortinvec ves, ‘SOMETIMES Noryer A Donsyerchldnoe wnindbyvabingebertnemingenre = o «10 hands and knees? ; 5. oes your cid walk well and seldom fl og fe) o «WD 6. Does your eid ci onan objec suchas a chair to reach something Ge. 10 eee he wants (or example, to get toy on a counter orto “help youln the kitchen? 45 GROSS Mo FINE MOTOR ves SoMETMES—_NoTveT 1. Does your child help tum the pages ofa book? (You may ita page for oS O° o «CLG her to grasp.) ° ha YK 2. Does your child throw a small ball witha forward arm motion? (fhe simply drops the bal, mark “not yet” for ths item.) O° y bee Does your child stack a small lock or toy on top of another one? (You ‘ould also use spool of thread, small boxes, oF toys that are about 1 inch in size) d d ° O° ‘Does your child stack three small blocks or toys on top of each other by oY 0. wt mae Oo Does your child make a moikon he paper withthe tp E BR a rehpowerpeal organ when mingtocow? IS ° ° is Vee O10 exeyororion 1Q PROBLEM SOLVING Ss ‘SOMETIMES Norver } Oo ° Does your child turn the pages of a book by himself? (He may turn more than one page ata time.) 1._After you seribble back and forth on paper with a crayon (or pencil oF pen), does your child copy you by scribbling? (Ifshe already scribbles ‘on her own, mark “yes” for ths tern.) 2. Can your child drop a crumb or Cheerio nto a small, clear bottle (such ‘8 a plastic soda-pop bottle or baby bottle)? o. X fo) ° Aer ere ror yw ts tainer like a bow! or box? (You may show him how to do it) 1 4 Stges Guesonaies, hd Eton AZO, Suis Bor “101160300 1008 eeepc Bons ag Go Alten6, After 2 crumb or Cheeriois dropped into a smal, clear bottle, does PROBLEM SOLVING ( coninves) ASQ) 16 Month Questionnaire sess ‘After you have shown your child how, does she try to get ‘2 small toy that is slightly out of reach by using a spoon, stick, or similar tool? ° [ecu eee et GO tihon you gv him a ryon (ot penl pan? {your child tum the bottle upside down to dump it out? (You may show her how.) : 3 PERSONAL-SOCIAL ves. SOMETIMES 4. Does your child feed himself with spoon, even though he may spill some food? 2, Does your child help undress herself by taking off clothes like socks, hat, shoes, or mittens? 4. While looking at himself in the mirror, oes your child offer a toy to his ‘own image? 2. oes yur che play wt dl ar sted erin by aging tL O° 5. Does your child get your attention o tr to show you something by ° poling ov your hand or clothes? 6. Does your child come to you when she needs help, such as with wind- oe ing up toy or unscrewing ali from a jer? OVERALL ee eee ne Sa Ov Been psn ee tS16 Month Questionnaire page 5014 OVERALL | conrueso 2. Do you think your child tals lke other toddlers his age? Ifo, explain: Ow Co Whinever Dace warts te get our attention he likes te vse righ pike scream, E veniOnath ea ge ee Streaming. LC bint 3 7 Cyzghs) 7 Ars 7p ; 2. cafe nf wb your cd sat Woe, eh "Oe One fe : 5 _ \ 4 Do you thnk your il was, runs, and ibs ike other toddlers her age? Des Ow tro wp a 5. Does ithe parent have a fom history of childhood desnes or herng Ow Cw ~ w impairment? H yes, expan 6. Do youhave concerns about your chit vision yes, explain On Co ( - ) ee eet rca pe cseee ee eter ert yee erie Ow Go ‘Ages 8 Stages Quesionsies®, Th Eton ASO Sere & Bicker < — E101160500 Bios adi roche Planing Co ih reconeA rm 8 Doyou have any concems about your child's behavior? If yes, explain: 9. Does anything about your child worry you? If yes, explain 16 Month Questionnaire pose 406 Ous Fro Ons No. ‘Age 8 Stages Qustonnates®, Thi Eton ASO-3%), Sires & Bicker 101160600 (ary Pan rakes Pung Co. Al ighsrorowed(RAS ) 3) 16 Month as0-3 Information Summary "=r. 2ser tein eee isoeaoaens GOS [15 Chis name: 0 Cae Chi _ date of bith: OD ‘Administering program/provider: Was age adjusted for prematurity dee when selecting questionnaire? Yes Oo 1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User's Guide for details, including how to adjust scores if item ‘esponses are missing, Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total In the chart below, transfer the total scores, and fil inthe circles cortesponding withthe total scores. ato os 0 5 20 16381 B30 3 40 45 08S Grom Morr | 37.91 Fae Motor | 31.98 Problem Sohing | 30.51 | 2643 Personal Soci 2. TRANSFER OVERALL RESPONSES: Bolded uppercase cesponses require follow-up. See ASO-3 User's Guide, Chapter 6 Comments Comment: 2. Tsitecthrtedeshinngsr Cam) NO 7. Anymdial clon wes fo) Comment “ Comments ‘3. Understand mast of what your child says? ‘Yes) NO — 8. Concems about behavior? Yes & Comments Comments: 4. rand nbs ite terres? Ces) NO %. Other concert ves © Comments Comnenta oe 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 sil, to determine appropriate follow-up. If the chiles total score in the C= area, it's above the cutof, and the child's development appears to be on schedule. If the chiles total score i in the [5 area, iis close to the cutoff Provide learning activities and monitor. If the chiles total scores in the Il area, it's below the cutof, Further assessment with a professional may be needed. 4, FOLLOW.UP ACTION TAKEN: Check tht app S, OPTIONAL: Transfer ite responses Provide activities and rescreen in months. Ifo e dream eli X= response misngh Share ests wih primary heath care provider. —TiTs]s]a]s}e ____ Refer for (crle all that apply) hearing, vision, and/or behavioral screening. canal INTIS INN oferta primary heath care provider or other community agency (pecly come IY ISWY reason): oo t _—— Refer to early inteveton/eny childhood specal education ee oe rasenssialY TY IS INV Y No futher action taken at this te - I otter pec remus Y IV ISINIYI 101160700 en es a