(Questions about bshewon Quran PeXTEf traces detcrbes your chide Gone cm te onthe fl Caregivers wh 10 know the child wel 15-20 hou het! Fs per week with the chi Ind spend more than, should complete ASO:SE.2. Hlowing pag Please read each question carefully and check the wor Also, check the cicle @ ithe behaviors vconcine Please return tis questionnaire by you have any questions or concems about your child or about this questionnaire, contact: Thank you and please look forward to filing out another ASQSE-2in months, Does your child look at you when you talk to her? Does your child cling to you more than you expect? Does your child keto be hugged orcudea? Does your child talk or play with adults he knows well? 5. When upset, can your child calm down within 15 minutes? 6. Does your child seem too friendly with strangers? 7. Does your child settle herself down after exciting activities? & Does your child seem happy? o.| 0 Senge Cvatiomaer Sec Erotoal Second Eden ASOSEI™~ See, Qc, 6 Tory gee Seog 'P201600100 "Gass Pea Broan Rang Coe AE igharenered. wont O poe tatsJ Month Questionnaire ‘Check the bon [if that best deserbes your cds behavior Als, check the ence @ ithe behaviors concen i See cincam 9% Does your child cry, seream, or have 0 Peal ‘ry, Scream, or have tantrums for long periods of Ov 10. Is your child interested in things around him, ; 9 such as people, toys, and foods? 2 1. Does your child go to the bathroom by herself? (Reminders and help with wiping are okay.) 12. Does your child have eating problems? For example, does he stuff food, vomit, eat things that are not food, or 2 (Please describe) 13, Does your child stay with activities she enjoys for at least 15 minutes (other than watching shows or videos, or playing with electronics)? 14. Do you and your child enjoy mealtimes together? 15. Does your child do what you ask him to do? For example, does he ‘wash his hands or wait to take a turn when asked? 16. Does your child seem more active than other children her age? 17. Does your child sleep at least 8 hours in a 24-hour period? 18. Does your child use words to tell you what he wants or needs? _i@ o. | 9 o. | 0 5. | 0 o. | 9 Oo 0 | 2 ‘Ages Stages Qvestarraes® Soc: Emationa, Second Eden (AS0:5E 2%, Seren, Bich Teor, 201600200 "O 2085 Ped oahas btaing Cob AI gravee.child's behav Check the box [if that best deserbes your ‘Non check the cre (the behawor sa concern ] ANS crmon | F ocr ranery on | THSISA Soies i “Never” | concen “I don't like that," or "She's sad?” 20. Does your child move from one activity to the next with little difficulty (for example, from playtime to mealtime)? 21. Does your child explore new places, such as a park or a friend's home? 22. Does your child do things over and over and get upset when You try to stop him? For example, does he rock, lap his hands, spin, oF 2 (Please describe.) 23, Does your child hurt herself on purpose? 24, Does your child follow rules at home or at child care? 25, Does your child destroy or damage things on purpose? 26. Does your child stay away from dangerous things, such as fire and moving cars? 27. Does your child show concem for other people's feelings? For ‘example, does he look sad when someone is hurt? 28. Do other children like to play with your child? u 201600300 — rota romsonmat D. Seda Emedona Second Editon (ASCSE 2%, Squires, chr, 8 Twombhy. ‘©2015 Pad M Bookes Publi Co. nc All ighta reserved page 305siete Bee ei (@ASQISED sense erate nen 29. Does your child tke to play with other children? 30. Does your child try to hurt other children, adults, or animals (for ‘example, by kicking or biting)? 31. Does your child take tums and share when playing with other children? 32. Does your child show an unusual interest in or knowledge of sexual language and activity? 33. Does your child wake three or more times during the night? 34. Is your child too worried or fearful? If “sometimes” or “often or always,” please describe: wn Sha is al Su shales + Cries 35. Does your child have simple back-and-forth conversations with 0 you? For example: Parent: “h’s raining!” Child: “And cold outside.” Parent: “Let’s get your coat." Child: “! got it!” 36. Has anyone shared concems about your child's behaviors? If “sometimes” or “often or always,” please explain: 2: 261600400 fom ae Sie Sn fies ASO Sat. ih, LyA Month Questionnaire @ASQSE2) | OVERALL Use tne space below for addtional comments 37. Do you have concerns about your child's eating, sleeping, or toileting habits? If yes, please explain: os {Gre 38. Does anything about your child worry you? I yes, please explain: fie Ow ‘Age & Stages Qvestionsies®: Soc Emotional. Second Pro1600s0o “Cans Pod trons Rang Core Ab gaol page Sots[60 month information Summary sinner enema G&ASQ:SE?)) Gane {Gnu 0st 3p 2] chidswe hes date tie: of 1) penonwtocompinmsasose2 ACHIEY DIMI GIL crits age nants and dys ‘Administering programiprovder:__________ Childs gender: Male Female 1, ASQ:SE-2 SCORING CHART: ‘© Score items (2 = 0, V= 5, X= 10, Concern = 5). ‘* Tansfor the page totals and add them for the total score. '* Record the child's total score next to the cutof 2, ASQ.SE-2 SCORE INTERPRETATION: Review the approximate location of the child's total score on the scoring graphic. Then, check ofthe ere forthe score rests blow. oe) 70 eg ee A. Tre cles total score i in the area. Its below the cutot. Socia-emationsl development appears tobe on schedule. The Gils total scores inthe Em aen. t's clone othe cutfl. Review behaviors of concem and monitor The cits total score iin the tl aren, tis above the cut. Further assessment witha professional may be needed 3. OVERALL RESPONSES AND CONCERNS: Record responses and transfer parent/caregiver comments. YES responses require follow-up. . r feartur of doctors officers can 1-35. Any Concerns marked on scored items? ®& no 6 oO MPCOMING events wy wOHry aPNed Btdogs Sivaged 4 ct1GE 37. Eatng/eeping/siing concerns? YES) Comments: 38. Other worries? ©) comments: FIT OF JOBE ew Sit watons Cie Getting tonsil out) 4. FOLLOW-UP REFERRAL CONSIDERATIONS: Mark all as Yes, No, or Unsure (¥, N, U). See pages 98-103 in the ASQ:SE-2 User’s Guide. DL. Setting/time factors (e. the child's behavior the same at home as at schoo!?) ‘1 Developmental factors (.g,' the cis behavior related toa developmental stage or delay?) DU. Health factors (e.g. Is the child's behavior related to health or biological factors?) "DY. ramity/cderal actors 9. s the child's behavior acceptable given the cis cultural or far context? Have there been any soon events the cid’ te recent?) Y. Parent concerns (ei the paert/aragher express ay concerns about the childs behave? 5. FOLLOW-UP ACTION: Check all that apply. Prowl actin sod rescoon tf manth ‘Share results weh primary health care provider. __— Provice parent education materials. __— Provide information about available parenting classes or support groups. ‘Have soother caregiver complete ASO'SE-2. Let caregiver here (e.9., grandparent, teacher _—- Admicester developmental screening (e.g. ASO-2. __ Reales to early mtervention/eerly chidhood special education. __— Refer for sociahemnotionsl, beheviors, or mental health evaluation Lowe pOlible mental healih evaiudilon 4 concerns continue 8 Se Deco Sac eon Second Eon ASSET Ss rca 8 Toa P201600600 ” "Sassen beder heading Co, BBmpsa eos