57 months 0 days f \SQ3) 60 Month Questionnaire sowshasment 03 of the actwties nthe fellowing pager ae quesions about acoies babies may do Your baby may have ahead) cone 7 ewes described here, and there may be some your baby has not begun dong yet For each tem, please fil in the OF Cates whether your baby i doing the activity raguialy, sometimes, oF not yet Important Points to Remember: Notes: ih Teyench acy wth your baby tore muting 2 veqponee, WE indesreerglitiegtindowick ian chai een you ond your cid Make sure your child is rested and fed. TT @ Please retum this questionnaire by ee COMMUNICATION ves SOMETIMES NOT Yer 0 1. wrhaayourgunghelpbypsiningorepeaing dreciom, onsyor HO o Ww child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down,” or “Give me the pen, open the book, and stand up.” 2. Does your child use four- and five-word sentences? For example, does we Oo oO 10 pour cid sy,“ want he car"? Please write an example Cm you vead mre & book? 3. When taking about something that already happened, does your child h oO @ lo Fen ait endin ed.” sich a “walked “jumped,” or “played”? Seno ental questions such a How cid you get othe store?” ("We ei 2er Wrst aed you do at your fend’s house?” (We played”) Please write an example: We glayed - We sKipped 4 Domyow dhl se comparaon words, ich a “hen” song” ag oO o «(6 On ee ne nck as "Aear aig bu abut See eat omanls ante) ATV 2 a ean ee fe, ene wile become Bugge page 2068 ‘Ages & Sages Qumabopaes,Thed Eon (ASO-2™) Stes bBo Bioieoo2ee ‘Sion Pea brooke Pubitng Co righ resorvedASQ COMMUNICATION s continued Does your cid ananer the flowing quent sone your child anaes ony one quesiony on Mak amaties Wat do you de when “get foe)” “eat Ficaes whe you 2 ye se hungry?” (Acceptable answers inclide ‘ask for something to eat," and “have a snack ”) iid’ response: — “What do you do when you are tired?” (Acceptable answers include “rest.” “go to sleep,” “go to bed.” “ie down,” and “ down.) Please write your child's response: x fate aANAp ov rest ox ap te ped 5. Does your child repeat the sentences shown below back to you, with- ‘out any mistakes? (Read the sentences one at atime. You may repeat ‘each sentence one time, Mark “yes” if your child repeats both sen- tences without mistakes or “sometimes” if your child repeats one ser tence without mistakes) Jane hides her shoes for Mara to fin. Al read the blue book under his bed, GROSS MOTOR 1. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw ‘overhand, your child must raise his arm to shoulder height | ‘and throw the bell foward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”) 2. Does your child eatch a large ball with both hands? (You should stand about § feet away and give your child two or ‘three tries before you mark the answer) 3. Without holding onto anything, does your child stand on fone foot fora least 5 seconds without losing her balance SPS porting her foot down? (You may give your child two or tree ties before you mark the answer) 101600300 60 Month Questionnaire ox !# vs sowermes Q oO Oo COMMUNICATION TOTAL norver iO1 £ 101600400 ing down the other foot” torr Stance of 46 feet ore Somann ct (207 Cou may gi egy e2ch foot. M, cy en ret ae ac ret rm Sia cee —=-————_—. ‘Ask your child to draw a picture of @ person on a blank sheet of Y on a blank sheet of py You may ask your child, “Draw a picture os gi or boy Wieoe ad draws 8 person with head, body. orms, andlang, rt ves child draws a person with only three parts these, body, coe, 9? mark “sometimes.” your chid drove» parece head, body, arms, or legs), mark “not yet Be tre to cade re sheet of paper with your child's drawing with the questomore Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a ‘more oF less straight line, making the blades go up and 4G) (_ down? (Carefully watch your child's use of scissors for safety reasons.) Using the shapes below to look at, does your child copy the shapes in the space below without tracing? (Your child’ drawings should look similar to the design of the shapes below, but they may be different in size. Mark “yes” ifshe copies all three shapes; mark “sometimes” if _your child copies two shapes.) + O A (Space for child's shapes) & 60 Month Questionnaire page 40/8 wooo ° > fe) a) ° ° Ba O° oO ‘Ages Stages Quertcnnaes®, Thc Edon (ASO) Squres&Brckar Peal Brookes Pubaing Co, A ghseerved IS B BB 5B pmAASQS, 60 Month Questionnaire page Sei8 FINEMOTOR YS sommes nore oe Ss ia ae ee ura ecu tre oye an | See er neewueemp ears ren nar ccna end you can read them) eet et) aaa! Mw Tc A (Space for child's letters) {Space for adult's printing) Cae) (Space for child’ printing) rnemoronrom 5. PROBLEM SOLVING ss | = 0 i o Bia eager rl odeincnelibyed eraperapebebrll ; _gesturing, oF looking at the smallest circle) OCO When shown objects z ° © ib ‘and asked, “What color is this?" ores oe ae o 2 name five different colors like red, blue, yellow, orange, black, white, Donk (Mart “yes” only f your Cold wnamersthe question core {eing tre colar) cuemanrarst Ted Eon ASO Sqn richer fase 8 eet ped bres enabing a A igs me 101600500When | throw the ball wp, comes d own (Mark “yes” ithe fishes three of fou sentences commecty, “sometimes” the iniahes two offer sentences somecte) nt ‘5. Does your child know the names of numbers? (Mart ys" she ident ‘es the three numbers below Mart “sometimes” if she identties two 3 1 2 6 Does your child mame atleast fow letters in her name? Point to the et- ‘tera and ask, “What letter is th?” (Point to the letters out of orcas) PERSONAL-SOCIAL 1. Can your child serve himselt, taking food from one container to ‘other, using utensils? For example, dows your dvd wae» large spoon to ‘scoop applesauce from a jer into « bow? 2. Does your cd wash her hands and face using soap ad water and dry off ith a towel without help? 3. Does your child tell you at least four of the following? Please mark the Items your child knows, Piet name D 4 va name Poe 5sAASQS 60 Month Questionnaire pape 70/8 PERSONAL-SOCIAL (comme) Foals! i= = ves sowemmes ——-NOTYET 4. Does your child dress and undress himslt, inclu ( Imedium-ze buttons and pang a oun Eon e® 0 2 5. Does your child use the toilet by hers? (She goes tothe bathroom, Oo O° S85 on the tollet, wipes, and Runhes} Mark "weer, i Star you verted hee ) 'yes" if she does this & Does your child usually take tums and share with other children? x ° ° PERSONAL SOCIAL TOTAL OVERALL Parents and providers may use the space below fr ational comments 1. Bo yout yor hil awl ew Ke Ow 2, Do you think your child talks like other children her age? ino, explain: Ons Ono hot te ocabularrs | Both Ap een [die « Lege Ue frl ot / oy \ 3. Can you understand most of whet your child 3537 no, explain Ow 4. Can other people understand most of what your child says? H no, explain Kes Ono 18101600700(ais ‘unin edison ine toe OVERALL conenes 5 Doyo ink ouch wa. maddie ect not Bus One | {& Dom ther parnt se andy eon citdhend desis orhening Ow Ow irpatmenth yu ean 7. Doyou have any concems about your cid vision? yes, explain Ow Re of 8 acacia Ku Ow Ap= twee te ER ff a ies | dtin by ENT Ls nae + 2 co Cngitoarmers| 5. Doyouhave any concems about your child's behavior? if yes, explain: Ow ro 10. Does anything about your chikd worry you? If yes, explain: Re Ow ( Tite GG ain he parlor meet meron ier S07 tet 101600800 ot a ga ne57 months 0 days through 66 months 0 days (BASQ3) 60 Month asa-s Information Summary ———__ bas ssoseaases 213 - te —__ Date of beth: ‘1. SCORE AND TRANSFER TOTALS TO CHART response te maaing.Seare eek hog Inthe cart below, Uanser he tees BELOW: See 450-3 Users Guide fr deta, including how o adjust scores item 10, SOMETIMES » 5, NOT YET =0) Add tom sore ond eer eo ae tata 2nd filin the crcies comesponding withthe total scores 20 2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6. 1 Hears well? (ey a 3 = & Family istry of heing impairment) YES © iatfin : 2. Tales bike other children hin age? yew HO!" 7. concerns shout wiion? ves fig “PATE beter and h fr vocapuiary c PAK BEER and have taiyer Eco butal 3 Uncantsnd tiated see) NO. 8. Animate oot ©) vo Comments: Comments: seen By i ERY Of Riehd ALM-ENT-cocooie “ough, 4 Others understand most of what your cil sys? (@ NO 9. Condemns about behavior? yes Feet, conics ce . towsts 5 Walks, rune, and dimbs ice other cidren? (NO 10. Other concerns? (3) No ‘cming Comments Comments: yt AEUIBIE feo ef dogs. par” yres HER Apel 3 sae SC Wire Netion A baccumsene TIM 7nPOULGHC UT rt la nd at ores oral : responses, and other considerations, such ‘8s opportunities to practice skills, to determine appropriate follow-up. ea id's tou Win the J area, 2 js above the citofi, and the child's development appears to be on schedule) ‘Gane er ioe sce 5 aa a cles Tot oll Provide evn acovies tnd anton Wine cudd't otal score sm the OB area, is below the cutoff Further assessment wth » profesional may be needed, 4. FOLLOW.UP ACTION TAKEN: Check a thet appt Provide acouthes and rveroan 6 month Share renuts wth premary healthcare prowder Inater tor (orca #8 that apply) hearing, waion, and/or behaworal screening, Rater to premary heath care provider or other <: onsen) ine Rater 1a early mtervention/earhy enidnood Ne farther acter aha at ths ne OPTIONAL: Transfer tem responses = YES, $= SOMETIMES, N = NOT YET, | xx