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    16 views8 pages

    Ages and Stages

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    api-379212464

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    © All Rights Reserved
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    48 Month ASQ-3 Information Summary "is 2d trough See eae Det SC amped chasio# onwef bit ‘Administering program/provider: 1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User's Guide for details, including how to adjust scores if item responses are missing. Score each itom (YES = 10, SOMETIME Inthe chart below, transfor tho total scores, and fillin the circles corresponding with the total scores, are | co | Kw [05 10 15 202530 Communion | 30.72 Grose Motor | 32.78 Fine Mot | 15.81 Problem Soking | 31.30 PowonatSocat | 26.60 3540 5, NOT YET = 0), Add item scores, and record each area total oO 0 oO Cjojojojoje lO|O|Ojo|o|s QjOjojo|o}# 2, TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6. 1. Hears well? Yes NO — 6. Family history of hearing impairment? Comments: ‘Comments: 2. Talks lke other childran his age? Yes NO 7. Concerns about vision? Comments: Comments: 3. Understand most of what your child says? Yes NO 8 Any medical problems? Comments: Comments: 4. Others understand most of what your child says? Yes NO 9, Concerns about behavior? Comments: Comments: 5. Walks, runs, and climbs lke other children? --Yes_-«sNO— 10. Other concerns? Comments: Comments: 3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UI fou must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up. Ifthe child's total score is in the 1 area, itis above the cutoff, and the child's development appears to be on schedule, Ifthe child's total score is in the EI area, iti close to the cutoft Provide learning activities and monitor. If the child's total score is in the mlm area, itis bolow the cutoff. Further assessment with a professional may be needed. 4. FOLLOW-UP ACTION TAKEN: Check all that apply, Provide activities and rescreen in___ months. Share results with primary health care provider. ves Yes, Yes YES ves OjO|ojojo|s Zz No No No 5. OPTIONAL: Transfer iter responses (Y= YES, S = SOMETIMES, N = NOT YET, X= response missing) i ala 4 6 Refer for (circle all that apply) hearing, vision, and/or behavioral screening, canal Refer to primary health care provider or other community agency (specify ar reason): ‘ Refer to early intervention/early childhood special education, sat) Problem Song No further action taken at this time Personal Soil Other (specify) Seren ‘Ages & Sages Questionnaires, Thi Edtion (ASO. Ste & Bricker 16 2009 Pal H Broskes Pblahing Co. Al ight resend. Ages & Stages ” Questionnaires* 45 month dys though 50 moths 30 ey Month Questionnaire Please provide the following informatio, Use black or blue ink only and print leaibly when completing this form ete ASA completed ‘Chile's information vee ciate Es chs ne Cate O male © Female ciidotine Person fling out questionnaire ftom wat tae Tepe sot Omi Orr Ogee cat Oren Osun Ore: © pr sertettee —_ Ogre Q gee on Hi Fe oa ots ‘County number ne Emel aden: Nema of people acting in gestion completon Program Information hig w Progam 0 Program nae ‘ees Sages Quesonnis®, The Edton (S03), Squier P101480100 {© Pel Brookes Mblahing Co Al ight eso 5 ie 45 months 0 dé 4B Month Questionnaire». whether your child is doing the activity reqularly, sometimes, or not yet. Important Points to Remember: Notes: Ty each acvty with your child before marking a response. Make completing this questionnaire a game that is fun for you and your child. 4 (Make sure your cid isrsted and fed a Please retum this questionnaire by COMMUNICATION vs 1. Does your child name at least thee items fiom a common category? ° ° ° For example, fyou say to your cil, "ell me some things that you can {2n," does your cd answer wth something te “cookes,egge, ond cereal"? Orif you say, “Tall me the names of sore animale" does your child answer with something ike "cow, dog, and elephant? SOMETIMES ——_NOTYET 2. Does your child answer the following questions? (Mark “sometimes” if Oo Oo O your child answers only one question.) “What do you do wen you are hungry?” (Acceptable answers include "get food," “eat,” “ask for something to eat,” and “have a snack.”) Please write your childs response: “What do you do when you are tired?" (Acceptable answers include “take a nap," “rest,” "go to sleep," "go to bed," "lie down," and “sit down.") Please write your childs response: 3. Does your child tell you at least two things about comman objects? For oO Oo Oo example, ifyou say fo your chil, "Tell mo about your ball” does she sey something lie, “I's round. I throw i e's big”? 4. Boos your child use endings of words, such a8 *-," "ed," and "ing"? oO oO O For example, does your child say things like, "I see two cats,” “I am playing,” or "kicked the ball"? page 207 ‘gos & tog Questinnies®, Thr Edin ASO-I™, Squire Bicker 101480200 or 4 S207 Fol broker Pushing Co. lighted (&ASQ3) 48 Month Questionnaire page 3of7 COMMUNICATION ( cersrea ves SOMETIMES NOTYET 5. Without your giving help by pointing or repesting, does your child fol O ° Oo low three directions that ere unrelated to one another? Give all three dlroctions before your child stars. For example, you may ask your child, “Clap your hands, wall to the door, and sit down,” or “Give me the pen, open the book, and stand up.” 6. Does your child use all ofthe words ina sentence (for example, “2,” Oo Oo O “the,” “am,” “is,” and "are”) to make complete sentences, such as "I am going to the park," or “is there a toy to play with?” or “Are you coming, too?” COMMUNICATION TOTAL _ GROSS MOTOR ves SOMETIMES, norver 1. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer) O O° oO — cS 2. Does your cil climb the rungs ofa ladder of a playground slide and Oo O° ° side down without help? 3. While standing, does your child throw a ball overhand in the Go Oo Oo direction of a person standing at least 6 feet away? To throw ‘overhand, your child must rie his arm to shoulder hetght and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”) L 4. Does your child hop up and down on ether the right or let foot at el O° O° Isast onetime without losing her balance or fling? 5. Does your chill jump forward a distance of 20 inches from a standing © O° Oo position, starting with his feet together? 4. Without holding onto anything, does your child stand on oO o O° ‘one foot for at least § seconds without losing her balance and putting her foot down? (You may give your child two. or three tries boforo you mark the answer) GROSS MOTOR TOTAL FINE MOTOR ves SOMETIMES. ——_NoTver 1. Does your chile put together a five- to saven-piace interlocking puzzle? Oo Oo ieee fone is not available, take a fullpage picture from a magazine or catalog and cut it into six pieces. Doos your child put it back together correctly?) 0 8 Staus Quesionaies TH Eon ASO Sites Bicker 101480300 Aoet8 fion Pad He behing Ca Al igo ASQ erates! : FINE MOTOR | fenins) vs soweraes Nort 2. Using child-safe scissors, does your child cut a paper in Oo Oo Oo oe halon a more o leas svaight bo maling the odes er 48 Month Questionnaire page 40/7 {g0 up and down? (Carefully watch your child’ use of scissors for safety reasons.) 3. Using the shapes below to look at, does your child copy at least three O Go Goa shapes onto a lange piece of paper using a pencil crayon, or pen, with cout tracing? (Your chit's drawings should look similar tothe design of the shapes below, but they may be different in size) Le tet |b 4. Does your child unbutton one or more buttons? (Your child may use his Oo a O own clothing ora dls clothing) 5. Does your child craw pictures of people that have atleast thee ofthe Oo oO ° following features: head, eyes, nose, mouth, neck, hair trunk, arn, hands, legs, o fet? 6. Does your child color mostly within the line in a coloring book or Oo ° Git within the lines of 2inchchele that you draw? (Your child should not

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