es & Stages (ASQ9) canon ot 36m Pace provid the feng efron. alco enol a print I on compe hi ee 3 moots 16 day trough 38 moths 30 days lonth Questionnaire ti inormation ies te ft owe Ome or got uote Somonomoan sent Ogg" Ont Com Program Information oom 8 101360100 (8 Re bodl bes sane aleg3) 36 Month Questionnaire you 3 mous Jose ‘On the folowing page we queions about aces diden may do Your dll may hav aed dane acme ofthe acts ‘deere re, ed therm may be sane you dd as not begun dng yet, For ach Rn, please fil in the ce that indeates ‘other your cil ding the sty rou sometines, ot Ye Important Points to Remember: Notes: © Toy each activity ih your ld bofore marking aspen. Make complotng thi quesicnnake a game that ifr for yan your dh Nees your en ested anc fe Place rota hie question by. COMMUNICATION ves sovermes—Norver 1. When you ask your cil o pit to hor note, eyes hak oot ats end) ° ° {orth dvs the correct pat oa last soven bod pare (he an points pats of hrf you, re de. Mark "somotines” she cor rectly poms to atlont tee Seent Body pats) 2. Docs your hid nak sentences that ate three or four word lng? ° ° o Please ge an exp: 28. Without ging your hil al by pining orang gestaes akhimto ° o — “pul he book onthe tbl an "put the she under th hak” Does your hid any ot bath ofthese Sections corey? 4. When looking at pctre Books your cil tllyou what is hap- fo} ° o peru or htt acto faking pace inthe plcure Ga example, "ark- Fro “ening” “eating” orig’)? You may se, "Wht the dog (Crop doing 5. Show your cil how appar on 3 cost moves up and down, ands, ° ° oO See thi goes up and dow. Pu the zipper to themida sk yourchid fe mathe spper do, Retam the ippar tot “Sela your child wo move the spper up. Do this several ines, placing ‘ha apper th msde bine iny your sito eon up ‘Bowe Does your child ons ne the per phen ou ay "ap" and dow when yousay "down"? {6 Whn you ak "What eyour ne?” dos your cll say bth or fist ° ° o — srl mes? COMMUNICATION TOTAL — 15101360200 fa a ee Rhea Co igutaie(AASQS) GROSS MOTOR 1 “ythoat holding onto anything for suppor, docs youre Keke bully aninging hi eg forward? ‘oes your child jump with both feat eaving the loo at the ‘ows your child wal up tat, using only one fot on toch eti2 (Pe a foo ton ane stp, and the ight fot ‘San the not) She may hold ort he raling oF wall Nou an look frist tre ona playground ort heme) ‘Boss your cd stand om one foot for about 1 second ‘whut holding ono anything? Whe standing, dove your cil trom a all ovethandby tals hiram to shouter lg and hong the all {arwar?(ropping the bal or ting the ball Undead ‘should be seared ae "not yet", Dos your chad jump Frward atleast inches with both {eet again the gourd at the same ine? FINE MOTOR Ata youre mtchs yuan sawtom aon | | ‘he papa othe otter wth a pon cayen, ore. {ihor to make alee yours Do rat ot you cid {inca yur ne Does your Cid copy you by amin tinge ne na vereal decton? 101360300 Ae aan aa broke Posen CoA 36 Month Questionnaire pse2617 O° oO — oO O° GROSS MOTOR TOTAL urea i. he(ASQ FINE MOTOR | fcccime 2, Can your dating sll toms sch bend, maar o pasta "wagon wheels" onto sting Crahoaace? xr cd yates yo sha singlet, hen OOF Cerrkes ie sysid Bowtie hin cay ——— Ge Boesyour ti copyyouty ron wchae? Sao BH 4A. Mioryour cid watches you draw ane tomene— —~ \\ ‘Hol thepaperte the ther sde ask orto make ‘nel yours Danott your cid 3680 Caraga fine Doss your chi copy yu by dawing 2 ainle : reesteheoadctber anf 5, Does your cl yo cut paper with cise aco He cove nst eed oct the paper ut mast got the Hadeste open and elose whe folding tho paper wih. the othe and. (a may show you eld how oven sor Carflly watch your ls use of sors fr safety reasons) (6. When dang, dows your cil ld panel rayon of pen betwssn her ngs and thumb ie on ad dos? PROBLEM SOLVING 1. Whi your ill watcha ne up four objects eo tock rears ina row Does yur child copy ox Inatato yous four objec ow? ‘an alsa we sped of ren, smal bones, o other tos 2. your cid wanes somethin sant eo dose find calor bboetostend on to each or sxampi to got a toy ona counter or Tp” youth the kitchen? 1101360400 108 er Of Oo Oo Oo Oo FINE MOTOR TOTAL oO Oo ‘36 Month Questionnaico sagt?(aasyy PROBLEM SOLVING | jonaos 3. When you point to the fire ad ak your il "Whats {30 does your ch sya word tht roars 3 person or amthing sna? (Mark yee for responses “sowman,” “boy.” "na." “gi” "Daddy “spacer,” and “monksy) Plata wie jour chi’ espone hrs 4. When you sn, "Sty “owen the dos your chil repeat at the two tunnbels inthe sme oe? Do not reat the numbers neces, tty mother pat of numba any, "Say ‘ght wo. (Yur eld mst repent ut Se sare tao numbers foro to awe "yor" to his ‘qustion) 5. Show your cil how to make aide wth locks, axes, tor canm ke the example, Does your child copy you by Imakng one his? {6 Whan you sy Saye ight thes" does your cl ropeat ju the thro manbers ine sane ode? Donat repet te number H neces try, ty anther sro of mbar antsy, "Says two.” (our ‘Hikmast epost it one series of reo nub for you to ater “estos quoton) PERSONAL-SOCIAL 4 Bos your cid ue spoon ta fou hota wth ie piling? 2, Does your hid ph aie wagon, stelle of toy on wel steering ‘Rovound bjacts and backing oof errs he canst tr? When youre isloking ina minor and you ak “Whe isin the mic {or door she sy aaher “me oe own nae?” 4. Does your child put ana cost, jake, shi by hil? 5. Using thoes erat weak il “Am ya gira hey [Boos your child anower cone? {Does your child take tun by waltg while arather ci rad takes stunt 0000 004 36 Month Questionnaire pagesut7 Oo Oo Oo fe} PROBLEM SOLVING TOTAL 00000 O° O° fe} O° ° O° ° PERSONAL-SOCIAL TOTAL 101360500 ‘SRea Gas nga ate,(@ASQ2) 36 Month Questionnaire pase sof” OVERALL Pont nd providers may se the pace blow for atonal comments. 1. Doyou inky hidhows loon Ow Ow 2, Doyouthinkyou cl tbs eter en eae? nse: Ow Ow 3. Canyouundestand ost of wht or di eo, oma Ow Ow 4. Cometh pope etand mont of ht orl oan Ow Ow 5. Do you think your child walks, uns, and climbs ike ot Ow Ono Wn, sel | oo cher parent have afar history ef eidod deofes or heting Ow Ono Implant? ye exp 18101360600 10 ee NiNbade naibey cat igieeedGASQ3) OVERALL fonines 7. Do you have any concen about your ciel vison? Hf ye, exp 9. Doyouhove any concern out your chills behavior’? yes, pain 10. Does snthing abou your dil wory your yes, expan 101360700 aiid Pehnge Atal ‘36 Month Questionnaire jue76t? Ow On On Ow Owe Ovo Ors Ono 498 up urls aie 0 he&, 3) 3G Month ASQ-3 Information Summary "Ys, cays tose hile ra (ns ASO compte cs 10 Date of bith Adinsesing progran/provider {1 SCORE AND TRANSFER TOTALS TO CHART BELOW Seu ASO Users Guide for deta ncuing how toast soe tem fexponec are ating Score each Rem (¥eS = 1, SOMETIMES ~§, NOT YET ~ O Ald tem cores, and rcord each are ota, Inte chat blow, ans the otal scots, nd il ith ccs cnresponding wth ha total oes Gate | 3699 Fonta | 1807 0s “OO Oo oO Oo 0 OO fe) Pests [35.38 Oo 4 Oo q oO fe) 2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses equ followup. See ASG User Guide, Chapter 1. Hears wal Yer NO 6 Famiyhisteryothearingimpaliment? YES No ‘Conant Comments: 2. Tea othor iden i 55? Yee NO 7, Concerns bout vision? YES No Comment: omar 2. Understand mos of what yourcidenys? Yee &_Any oda problems Yes No 4. Othe understand most of what your cid says? Yas NO 9%, Concerns sbout behavior? YES No Comat Comments: 5. Waksyrunsjandclinbske atherchiden? Yee NO 10. Other concerns? YES No Comment Comments 3. ASG SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOWUP: You nt consr ‘esponsen and ether eonitlons, sch ar oppotiniiesto practice ks, to dtarine appropriate felon 1 the childs total cores in the Cae ieabove the etl, ar the cs devlopment apps {the chs ttl cores inthe asa, close to the cut Provide aning ates and mono Ite chs total scores inthe Bat ste ls lo the cto. Further asesmant with profesional may be needed, 4. FOLLOWUP ACTION TAKEN: Choc tht opp. 5, OPTIONAL: Teaser item resporsas X- responce mizing Shares wit primary hea care provides = Prove settion and rescroen in mouths nn Retr fori alta pp hein, ton norbabmiontscweing, I eter pry hc poe eather emmy apie pet co a efor to oa ntrventiononycldhod spel education. raha No futher action taka atthe —— ther spi 108 ES pean bee naagee ganar 101360800