| 36 Month Questionnaire sinmnicodyeinghs note | | uestons shou behave chittenmoy have we lted on te alovng pages Pls rood coh question carly and chock he box that best errs your hi behavior As, heck he cre @ fhe behaviors concen Important Points to Remember: D1 Answer questions based on what you know about your EQ) Please return this quostonnaire by: ‘child’ behavior 1 youhave any questions or concerns about your child or Answer questions based on your cits usual behavior, about this questionnaire, contact not behavior when your cid is sick, very red. o hungry. EY Thankyou and please look forward io filing out ancther 1 Coreqvers wo know the child well nd spend more than ASCASE-2in months 15-20 hours per week with the chi should complate ASQ:SE-2, oe oe ee eon aoa oalne. 2. Doos your childlike to be hugged or cuddled? 5. When upset, can your child calm down within 15 minutes? & Does your child soem too friendly with strangers? 7. Does your child settle herself down after exciting activities? ov 10) TOTAL POTS on pace 5 Dees clement cee eee 20136010 “rm ome er nn st ae36 Month Questionnaire Check the box [af 10. 12, 2. 14. 15, 16. "7, 1. Does your child move from one activity to the next with little difficulty (for example, from playtime to mealtime)? Does your child seem happy? |s your child interested in things around him, such as people, toys, and foods? Does your child do what you ask her to do? Does your child seem more active than other children hs age? Does your child stay with activities she enjoys for atleast 'S minutes (other than watching shows or videos, or playing with electronics)? Do you and your child enjoy mealtimes together? ‘Does your child have eating problems? For example, does he stuff food, vomit, eat things that are not food, or (Please describe.) iod? Does your child sleep atleast 8 hours in a 24-hour ps Does your child use words to tell you what she wants or needs? ao. alo fo 1P201360200 ‘AoW & Sones Queso Socal Enotionl SacndEdhion ASCE 29, Sis, Bch, Two "SOS Pa role abing Co nA nh ean - rom ronsouraceanna te taps in 18, Does your child follow outne drecton? For example, doeshe | pf come to the table or help clean up his toys when asked? aid | oO 0 o. |O 1%, Does your child ey seam, orhave tantrums for lon periods of time? 2 ao: 20. Does your child check to make sure you are near when exploring new places, such as a park or a friend's home? a | of & 21. Does your eid do things over and over and getupsetwhenyou | oh, | Oy |p O tty to stop her? For example, does she rock, fap herhands, spin, | F® | Ov | Ov or? Plesse deseibe) 22, Does your child hurt himself on purpose? 23, Does your child stay away from dangerous things, such as fire and moving cars? 24, Does your child destroy or damage things on purpose? 2. Donsyourchid wn were deonbortecngs ttn | a | Cy | feelings of others? For example, does she say, “'m happy,” "Ton lke that” of "She's sod"? 28. Can your child name a friend? fl Oo TomaLrontson pace 3 1 ses Cusine: acl Enon, cs on ASO SE Sain Bch, Tom 201360300 es "Sata ces bing Can Al ighs rn 7 ade36 Month Questionnaire (RASQSED) oss apercrin ort te 22. Do other cian ie to ploy wih youre? tio aolo}/O 28. Does your childlike to play with other children? 29. Does your child ty to hurt other children, adults, or animals for ‘example, by kicking or biting)? Q k 30. oes your child show an urusual interes nor knowledge of oO sexual language and sty? 31. Does your child ty to show you things by pointing at thom and ero) looking back at you? jo 32, Does your child pretend objects are something else? For example, does he pretend a banana is aphone? 33. Does your child wake three or more times during the night? QO \ 34. Is your child too worried or fearful? If “sometimes” or “often or always," please describe: ° le a ° | 35. Has anyone shared concerns about your child's behaviors? If “sometimes” or “often or always,” please explain: ToraLromtson mae 0 201360400 Ae ea ee ti a has Cane MIT Ses Ms, 8 amb pine sof36 month Questionnaire OVERALL Use he space below fer aden commons 36, Do you have concerns about your childs eating sleeping, or toileting habits? Ifyes, please explain: Ow @ 37. Does anything about your child worry you? If yes, please explain: 38. What do you enjoy about your cid? Ja lkative, and Drie endly, she is and how wis tp ottos. 201360500 tee ee Tpit ccs SNS Cte Miagraresese sem pages ot5