(Qh ASQ3) Ages & Stages Questionnaires® 16 15 months 0 days through 16 months 30 days Month Questionnaire Please prove the following information. Use black or be ink only and print legibly when completing his form, 50 complete: Child's information aw Mo i fest as me Ohta ae Fh wesien chads gender conor vee Prenat of O we © Forme hit de ti Se renatce Person filling out questionnaire ite ft a Mit Lantcae sortp to Orson © suntan CO) tesehe © Sega suet ade reaent Cente a Ossie Fame © ter so zr oy Fhe Felt code cs oi coun Sa” Sa Ema adios Names of people assting in quostionn completion: Program Information chad Ag a administration in months ere aye Program 0 Irprematue, adsted age a moths and days Program name! ‘Ages B Stages Questionsres, Tid Editon (ASO.3™), Squires 8 Bricker P101160100 (© 2007 Paul H. Brookes Publishing Go, Al ahs eseved,16 Month Questionnaire rough encom sods On the following pages are questions about activitis children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please ln the circle that inckcatos ‘whether your child is doing the actwity regulary, sometimes, or not yet Important Points to Remember: Notes: Try cach activity with your child before marking a response. Moko completing ths qustonnate a game thats fun for you and your chi Make sure your child is rested and fed, 4 Please return his questionaire by At tis age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your child more than one time. If possible, try the activities when your child is cooperative. If your child can do the activity but refuses, mark "yes" for the item. COMMUNICATION 1. Does your child point to, pat, or try to pick up pictures in a book? SOMETIMES NOTYET 2. Does your child say four or more words in addition to "Mama" and "Dada"? 3. When your child wants something, does she tell you by pointing to it? CHOW OH@ia 00 00 CHOP ONG: | 4, When you ask your child to, does he go into another room to find a fax miliar toy or object? (You might ask, “Where is your ball?" or say, "Bring me your coat,” or "Go get your blanket") ° ° ° | 5. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as “Mama est," “Daddy play” “Go home," or "What's this?" does your child say both words back to you? (Mark "yes" even if her words are difficult to understand.) 4, Does your child say eight or more words in addition to "Mama" and Oo Oo Coie ia "Dada"? COMMUNICATION TOTAL == —__ GROSS MOTOR ves SOMETIMES, Not yer 1 Does your child stand up in the middle ofthe floor by himself and take Oo oO Owe several stops forward? 2. Does your child climb anto furniture or other large objects, such as oO O Oo large climbing blocks? 3. Doss your child bend over or squat to pick up an object from the floor oO oO Ova and then tend up again without eny support? page 2086 ‘Ages 8 Stages Questionnaires, Third Edin ASC.) Squree 8 Bicker £101160200 {92009 Poul H, Bookes Publsing Co Al dghtaresarvedges of (&ASQ3) aa : 16 Month Questionnai GROSS MOTOR continues) ves SOMETIMES Norver Oo oO — 4, Does your child move around by walking, rather than crawling on her hands and knees? oO 5, Does your child walk wall and soldom fall? Oo Oo Olgas oO oO Oo —_ 6, Does your child climb on an object such as @ chair to reach something he wants (for example, to get a toy on a counter or to “help” you in the Kitchen? GROSS MOTOR TOTAL = FINE MOTOR ves sowermes _NoTveT 1. Does your child help tun the pages ofa book? (You may if a page for oO oO One her to-grasp) 2. Does your child throw a smal ball with a forwerd arm motion? Oo Oo Oia (ifhe simply drops the ball, mark "not yet” for this item.) 3. Does your child stack» small block or toy on top of another one? (You ° ° Ones could also use spoo!s of thread, small boxes, oF toys that are about 1 inch in siza) 4, Does your child stack thee small block or toys on top of each other by oO oO Ouse herself 5. Does your child make a mark on the paper withthe tip zi ° Oo Oat ae ‘of a crayon (or pencil or pen) whan trying to draw? iis 4. Does your child tun the pages of a book by hime? (He may tum ° O° Oa more than one page at a time,) FINE MOTOR TOTAL = __ PROBLEM SOLVING ves. SOMETIMES, Norver 1. ter you serble back and forth on paper with a crayon (or pencil or Oo oO o ~~ pen), does your cd copy you by srisbling? (she already srfbblae ‘on her own, mark “yes fr this em) 2. Can your child drop a crumb or Chesrio into a small, clear bottle (such ° ° On a8 aplastic sode-pop bottle or baby bottle? 3. Does your child drop soveral small toys, one after another, Into a con- oO Oo @ceteae tainer like a bowl or box? (You may show him how to doit) 0 Stages Qmronnsies, Thi Eon ASO-I, Sse char 101160300 Aoee 8 Sn taal broker Publaig CoA igh ese(BASQ3) : ae PROBLEM SOLVING | (in) 4. After you have shown your child how, does she ty to get ‘a small toy that i slightly out of reach by using a epoon, stick, or similar tool? o 5. Without your showing him how, does your child scribble back and forth when you give him a crayon (or pencil or pen)? 4. After a crumb or Cheerio is dropped into a small, clear bottle, doos your child turn the bottle upside down to dump it out? (You may show her how) PERSONAL-SOCIAL 1. Does your child feed himself with a spoon, even though he may spill some food? 2. Does your child help undress herself by taking off clothes like socks, haat, shoes, or mittens? 3. Does your child play with a doll or stuffed animal by hugging it? 4. Whi looking at himsotfin the mirror, does your child offr a toy to his age? 5. Does your child get your attention or try to show you something by paling on your hand or clothes? 6. Does your child come to you when she needs help, such as with wind: Ing up a toy or unserewing a lid from a jar? OVERALL Prents and providers may use the space below for additional comments 1. Do you think your child hears well? If no, explain: ves ves oo 00 0 0 16 Month ax SOMETIMES 3 ie) oO fonnaire page sors Nor ver oO — eee One PROBLEM SOLVING TOTAL = “If Problem Sowing kom 5 ls marked "yes," mark Problem Solving SOMETIMES Oo Ge Gan ©): Oo ‘tem 136 “yes” Oe oOo 00 0 PERSONAL-SOCIALTOTAL = __ Ows Ovo ‘Agee & Stages Quertionnsina®, Third Eaton (ASO-3™), Sais 8 Bckor 101160400 (0 250 Poul H.BrokesPublahing Co. Al rights reseed,@ASQD 1S Month Questionnaire pron sors OVERALL ccominues) 2. Do you think your child talks like other toddlers his age? if no, explain: Ones Ono 3, Can you understand most of what your child says? If no, explain: Ons Ono 4. Do you think your child walks, runs, and climbs like other toddlers her age? Ovs Ono ifn, explain: rc 5. Does either parent have a family history of childhood deafness or hearing Ons Ovo impairment? Ifyes, explain: 6. Do you have concerns about your child's vision? If yes, explain: Ons Ono 7. Has your child had any medical problems in the last several months? If yes, explain: Ors Ono 1 & Sages Qusionsres® Thin Eon 150.2), Sule 8 her 101160500 Pee 8 Coes Ped Bock Rating GA tae ecardASQ 16 Month Questionnaire _pagesets OVERALL feominses 8. Do you have any concerns about your child's behavior? If yes, explain Ovs Ono 9. Does anything about your child worry you? If yes, explain: Ove Ono Tir Eton (A503), Squws 8 Bor E101160600 rd‘Four __ a Child's namo Date - Ago a Relationship to child M-CHAT-R™ (ifoditid Chisoiat for Auth in Todelivs Roviesd) esse anster these questions about your child. Koop in mind bow your child usualy behavos you havo Seon you child do the bohavoe a fow tines, uth oF ‘he dows not ueualy dof, thon pesae answer no, Please cielo yea or no for every quoson Thank ou vory mush, 4, Ifyou point at something across the room, does your child look at it? Yes No (FOR EXAMPLE, if you point at a foy or an animal, does your child look at the toy or animal?) 2, Have you ever wondered if your child might be deat? Yes No 3, Does your child play pretend or make-bollove? (FOR EXAMPLE, pretend to drink Yos No from an empty cup, pretend to talk on a phone, or pretend fo feed a doll or stuffed animal?) 4, Does your child lke climbing on things? (For EXAMPLE, furniture, playground Yes No equipment, or stairs) 5. Does your child make unusual finger movements near his or her eyes? Yes No (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?) 6. Does your child point with one finger to ask for something er to gét help? Yes = No (For ExawPLe, pointing to a snack of toy that is out of reach) 7. Does your child point with one finger to show you something interesting? Yes No (For EXAMPLE, pointing to an airplane in the sky or a big truck in the road) “6.18 your child interested in other children? (FoR BXAMBLE, diods\ jour child Wate ~~ “Yes” Né other children, simile at thers, or go to them?) ‘9, Does your child show you things by bringing them to you or holding them up for you to Yes No 800 —not to get help, but Just to sharo? (FOR EXAMPLE, showing you e flower, a stuffed animal, or a toy truck) $0, Déds your eh respond wien yeu Gall Ris or Her Ramee (POH EXAMPLE, deosifié'or she” ‘Yes look up, talk oF babble, of stop what he or she is doing when you eall his or her namie?) 414, When you smile at your child, does he or she smile back at you? Yes No 712 Does: Your child gel lpset by everyday nolsés? (FOR EXAMPLE, dacs Your ~ | Yes” NG ‘Giilld scream or ely to nolse such as a vacuum cleaner of loud music?) oe Se erase ereett 18, Does your child walk? Yes No 714; B88 your child’ lok you in the Gye When liiig with hing © ~~~ Yes” “No of her, or dressing hin or her? 418. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or Yes No make a funny noise when you do) 16; F you turn your head fo look at something, doss your oftd |dok around to seo what you Yes No até looking at? 17. Does your child try to get you fo watch him or her? (FoR EXAMPLE, does your child Yes No look at you for praise, oF say “look" of "wate me"2) 18, Doss yourchiid understand when youtel him orher ts do gortening?: Yes No ‘OR EXAMPLE; If You don't polit, can your child understand *put the book ‘on the ehalt” of "bring me the blanket"?) 19. lf something new happens, doos your child look at your face to see how you feel about it? “Yes. ~—-No (FoR EXAMPLE, if he of she hears a strange or funny noiso, or sees a new toy, will he or sho look att your face?) 20. D0e5 your child like movement activities? Yes No (FoR ExamPLe, boing swung or bounced on your knoe) 2009 Diana Robins, Deborah Fein, & Marianne BartonOffice Use Only a& 3) 16 Month ASQ-3 Information Summary 1°" Oday touch Che name Dote ASO completed Chis De Date of bith Administering program/provider, ____ Was age adjusted for prematurity whan selecting questionnaire? Q)Yes O/No 1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User's Guide for details, including how to adjust scores if tem responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET « 0). Add item scores, and record each area total Inthe chart below, transfer the total scores, and fil in the circles corresponding with the total scores, awe lewor | ful os 1 15 2 25 3050S SSW ‘Communication | 16.81 Grose Motor | 37.91 Fre Morr | 31.98 Problom Sebing | 30.51 PetsonatSocal | 2643 2, TRANSFER OVERALL RESPONSES: Bolded uppercase responses roquite follow-up. See ASQ-3 User's Guide, Chapter 6. 1. Hears weil? Yes NO 6 Concems about vision? YES No ‘Comments: Comments: 2, Talks ike other toddiors his age? Yes NO 7. Any medical problems? YES No Comments: ‘Comments: 3. Understand most of what your child says? Yes NO & Concerns about behavior? YES No Comments: Comments: 4. Walks, runs, and climbs lke other toddlers? —--Yes.:«SNO 9. Other concerns? YES No Comments: Comments: 5. Family history of hearing impairment? YES No ‘Comments: 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 skills, to determine appropriate follow-up. IF the child's total score is in the [5 area, it is above the cutoff, and the child's development appears to be on schedule, IF the child's totel score is in the EE area, itis close to the cutoff. Provide learning activities and monitor. If the child's total score isin the Ill area, iis bolow the cutoff. Further assessment with a professional may be needed, 4. FOLLOW-UP ACTION TAKEN: Check all that apply. 5, OPTIONAL: Transfer ito responses (Y= YES, § = SOMETIMES, N = NOT YET, X= response missing). Provide activities and rescreen in__ months. Share results with primary health care provider. Taleletste Refer for (circle al that apply) hearing, vision, and/or behavioral screening, Smal Refer to primary health care provider or other community agency (specify Gon Mawr reason): ‘ i 7 ; Fra Noto Refer to early intervention/eatly childhood special education, Probie Sobing ____ No further ection taken at this time Pereonal Soca thor (speci ‘Ages & Sagas Qvstonnstee, Third Eton (ASI) Sguks 8 ick 101160700 oe 8 So Pad Desks Pubiaiog Cad ahve