28 months 16 days &ASQ3) 30 Month Questionnaie yn tie ‘On the following pages are questions about activities children may do, Your chill 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 fil n the circle that indicates whether your child is doing the activty regulary, sometimes, or not yet. Important Points to Remember: Notes: Try each activity with your chil before marking a response A Make completing this questionnaire a game that is fun for pleting this g 9 you and your child 1 Make sure your chit is rested and fe A Please return this questionnaire by. COMMUNICATION 1. thyou pinto» piere ofa bal ity, cup, hat ete) andaskyour child, Whats ths?” does your chil conecty nome a least one pleuwe? 2. Without your giving him clues by pointing or using gestures, can your O° oO oO child cary out atleast three ofthese kinds of directions? © arpa © b "Close the door” © €-"Take my hand.” yy onthe rable" ©) d. “Find your coat.” © 6 "Bring me owel O f."6et your book.” 3. When you askyour child to point to her nose, eyes, har fect, eas, and Oo ° o ~— se forth, dows she correctly point to at least seven body pars? (She can point to parts of herself you, ora doll. Mark “sometimes” f she cor rectly points to atleast three diferent body parts) 4. Does your child make sentences that are three or four words long? ° oO oO — Please give an example 5. Without giving your child help by pointing or using gestures, ask him to ° ° oOo — ‘put the book on the table” and “put the shoe under the chair” Does your child eary out both of these directions correct? 6. When looking at a picture book, does your child tell you what 's hap- ° Oo Oo — ‘or what action is taking place in the picture for example, “bark: running,” “eating,” or “crying")? You may ask, "What is the dog (or boy) doing?” COMMUNICATIONTOTAL = —_ page 2047 [Ages & Stages Questionnsves, Third Edtion ASO), Saies & Becher 101300200 1 Sa00 Poul Brosces Pubtahing Ca. Allights reserve(&ASQ3) 30 Month Questionnaire page 3017 GROSS MOTOR ves ‘SOMETIMES notver 1.._Does your child run fatly well, stopping herself without bumping into things or falling? O° oO Oo — 2. Does your child walk either up or down at least two steps. by himself? He may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.) 3. Without holding onto anything for suopert, dees your child kick a ball by swinging his leg forward? 4. Does your child jump with both feet leaving the floor atthe Oo ° o same time? 5. Does your child walk up stairs, using only one foot on each, stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall & Does your child stand on one foot for about 1 second Oo ° o ~— without holding ante anything? GROSS MOTORTOTAL = —__ "Hf Gross Motor tem 5 ie marked “yer” or "sometimes," mark (Grose Motor item 2 “yee Ages & Stage: Questonnaves®, Tid Edtion A505"), Sauces & Bricker 101300300 1 2009 Pau Bross Publshing Co. Aight reseneASQ3 30 Month Questionnaire pase 4017 FINE MOTOR 1 Does your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or serew lids on and of jars? Aer yourchldwatdes you daw ane om theton ot | thepaper ote batom witha pene cayen.cr pensask | him to make a ne Ike yours, Do not let your child ace, ——————— Yourline: Does your chid copy you by erawing a single Coumtu line ina vertical direction? “CY Can your child string small items such as beads, ‘macaroni, or pasta “wagon wheels” onto a string or shoelace? Ateryurctadwacter yuna ng tom ene fide of the paper tothe other side, ask herto make <> fine ke yous Do not tyour ent race your Tne Doss your child copy you by drawing single ete nate line ina horizontal direction? aN) cnet yt [ter your child watches you daw asinge cele, ak him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a Counras nate” we coe, Does your child tum pages in a book, one page at a time? PROBLEM SOLVING 1 2. your child wants something he cannot reach, does he find a chair or box to stand on to reach it (fr example, to get a toy on a counter or to “help” you in the kitchen)? ‘Ages & Stages Qustionnsives, Third Elion ASO. 101300400 10 Ba09 Poul Brosces Publahing Ca. Allights eserves When looking in the mirror, ask, "Where is ” (Use your child's name.) Does your child point to her image in the mirror? ves Oo ° O° — oO O — Oo Oo — FINEMOTORTOTAL = SoMEMMES —-NOTYET ° °O — oO Oo — 1), Squires & BrickerASQ3 30 Month Questionnaire pase sof? PROBLEM SOLVING coninsea) 3. While your child watches, line up four abject like block or cars in a row. Does your child copy or imitate you and line up four objects in a row? (fou can also use spools of thread, small boxes, or other toys.) 4, When you point to the figure and ask your child, “What is this?" does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” "gir," "Daddy." "spaceman,” and “monkey.") Please write your child’s response here’ 5. When you say, "Say ‘seven three,"" does your child repeat just the two ‘numbers in the same order? Do not repeat the numbers. H necessary, ‘ty another pair of numbers and say, "Say ‘eight two.’ Your child must repeat just one series of two numbers for you to answer “yes” to this question, 6. Alter your child draws a “picture,” even a simple scribble, does she tell you what she drew? (You may say, “Tell me about your picture,” or ask, “What is this?” to prompt her) PERSONAL-SOCIAL 1. you do any of the following gestures, does your child copy at least cone of them? © 2.Open and close your mouth. CQ) «, Pullen your earlab. Ob Blink your eyes O 4-Pat your cheek 2. Does your child use a spoon to feed himself with ile spiling? 3. Does your child push alittle wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she cannot ra? 4. Does your child put on a coat, jacket, or shirt by himself? 5. Alter you put on loose-fiting pants around her feet, does your child pull hem completely up to her waist? 6. When your child is looking in a mircor and you ask, "Whois in the mir. +01?" does he say either “me” or his own name? O° Oo o — Oo — PROBLEM SOLVING TOTAL = __ Oo oO o ~~ PERSONAL-SOCIALTOTAL = —_ [Ages & Stages Qustionnsives, Third Edltion ASO), Saies& Bicker 101300500 10 Ba09 Poul Brosces Publahing Ca. Allights eserves(&ASQ3) 30 Month Questionnaire pase 6017 OVERALL Parents and providers may use the space below for additional comments, 1. Do you thine your child hears well? Ino, explain: Ons Ono 2. Do you thnk your chill talks ke other toddlers her 296? Ifno, explain: Ows Ono 3. Can you understand most of what your child says? If no, explain: Oxs Ono 4, Can other people understand most of what your child says? If no, explain: Ons Ono 5 Deyo neous an dibs tied hip Ovs Ono 6. oes sther parent havea fail history of childhood deafness or hearing Ous Ono impatient? Iyer, expla Ages & Stage: Questonnaves®, Third Edtion A503"), Squces& Bicker 101300600 162009 Pau Bross Publshing Co. Alright resene30 Month Questionnaire pase 70f7 (ASQ OVERALL conned 7, Do you have any concems about your childs sion? Hye, xpi: Ous Ono 8. Has your child had any medical problems inthe lst several months? yes, explain Os Ono | 9. Doyou have any cancems about your chil’ behavior? Ifyes, explain Ow Ono | 10. Does anything about you child worry you? Ifyes, explain Ovs Ono Ages & Stage: Questonnaves®, Third Edtion A503"), Squces& Bicker 101300700 162009 Pau Bross Publshing Co. Alright reseneChild's name: Child's 10 #: Administering program/provider: Date ASQ complet 30 Month ASQ-3 Information Summary 78 orths 16daye touah Date of birth 1, SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASO-3 User's Guide for details, including how to adjust scores ifitem responses are missing. Score each item (YES Inthe chart below, transfer the total scores, and illin the circles corresponding with the total scores. 5 50 10, SOMETIMES = 5, NOT YET = 0). Add iter scores, and record each area total. 15 2530 Ole Ojols ee 3 Oo ares | cot Conmaveaten | 33.30 Gress Mover [36.18 Fre Mower | 19.25 Problem Sebing | 27.08 Peronatseci | 32.01 ee) lO} lQojojojojs 1} OJO|OJOJO}# lO} IOJOJOMO} Oo O O O ee) 2, TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6 1. Hears well? Yes NO 6. Familyhistory of hearing impairment? YES Comments: Comments: 2. Talks like other toddlers his age? Yes NO 7. Concerns about vision? Comments: Comments: 3. Understand most of what your child says? Yes NO & Anymedical 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 like other toddlers? --Yes_-«sNO_— 10. Other concerns? Comments: Commer 3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must conzider total area scores, overall Yes Yes Yes Yes responses, and other considerations, such a8 opportunities to practice skils, to determine appropriate follow-up, If the child's total score is in the (5 area, If the chile’ total score is in the area, is close to the cutoff Provide learning activities and monitor. Js above the cutoff, and the child's development appears to be on schedule. If the chile’ total score is in the lll area, its below the cutoff. Further assessment with a professional may be needed. 4, FOLLOW-UP ACTION TAKEN: Check all that apply Share results with primary health care provider, Refer to primary health care provider or other community agency (specify reason): Provide activities and rescreen in__ months. Refer for (circle all that apply) hearing, vision, and/or behavioral screening No No No 5. OPTIONAL: Transfer item responses {Y= YES, § = SOMETIMES, N= NOT YET, X = response missing). 22/4 Refer to early intervention/early childhood special education No further action taken at this time Other (specify) P101300800 Problem Sehing Persona Socal [Ages & Stages Questionnsives, Third Edtion ASO"), Sauies& Bicker 1 Ba00 Poul Brosces Pubtahing Ca. Allights eserves