AASQ3) Ages & Stages er Mo rn * Questionnaires® I 23 months 0 days through 25 months 15 days Jf 24 Month Questionnaire \ Please provide the following information. Use lack or blue ink only and print oT IXY | Io won comping thorn {(/ EY Date ASQ compote Wr > Child's information Middle Chl’ fst name: Ina Chie’ lst name hid gender Ore O Female (hile dat of bie Person filling out questionnaire Oram © Gunton O)ascner C) Sere Sessa —____ 0 gigwert fur ote _ Sat ois ‘Country: fumbor see Ena oes Names of people assisting in questionnie completion: Program Information hia Program 1 Program name: ‘Ages & Sages Qustonnsies®, Third don (A803, Squkes & Biker P101240100 ‘8 9 000 Pal rocks Pubihing CoA igh esoed‘&ASQ3) 24 Month Questionnaire oun sons odo ‘On the following pages are questions about activities babies may do. Your baby may have already done some of the acthities described here, and there may be some your baby has not begun doing yet. For each item, please fil in the circle that indi- ‘cates whether your baby is doing the activity regularly, sometimes, or not yet 3 Please return this questionnaire by Important Points to Remember: Notes: Try each activity with your baby before marking a response. Make completing this questionnaire a game that is fun for you and your child s aw Make sure your child is rested and fed, ‘At this 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 ves SOMETIMES Nor yer 1. Without your showing him, does your child point to the correct picture Oo Oo on wen you say, “Show me the kit,” or ask, ‘Whereis the dog?” (She needs to identify only one picture correctly) 2. Does your child imitate a two-word sentence? For example, when you Oo O° o ~~ say two-word phrase, such as "Mama ea,” “Daddy play,” "Go home,” or “What's thi?” does your child say both words back to you? (Mark "yes" even if her words ae difcult to understand) 3. Without your giving him clues by pointing or using gestures, can your Oo Oo Oo _ child cary out at least three of those kinds of directions? O a*Putthe toy on the table." OQ) a.nd your coat" O b.close the door" Oe "Toke my hand.” O "Bring me a towel O f"Getyour book.” 4. you point to a picture of a bal ity, cup, hat et.) and ask your child, O Oo Oo “What is this?” does your child correctly name at least one picture? 5. Does your child say two or three words that represent diferent ideas Oo ° o ~~ together, suchas "See dog," "Mommy come home," or "Kity gone"? (Don't count word combinations that express one idea, such a6 “bye bye," “all gone,” “alright” and “Whats thot?" Please give on ox. ample of your child's word combinations XQ page 20f7 ‘Ages & Stages Questionssies®, Third Edin (ASO-3™), Squires & Bicker 101240200 192009 PaulH. Brookes Publishing Co, Alright reserved(@ASQ3 COMMUNICATION tonves 6. Does your child correctly use at least two words lke “me,” "I," “mine,” ‘and “you"? GROSS MOTOR 1. Does your child walk down stars if you hold onto one of her hands? She may also hold onto the railing or wall. (You can look for this at a store, on playground, or at home.) 2. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (Hf your child already kicks a ball, mark "yes" for this item.) Pr . 2. Doos you cil wa ether up or down at last wo steps | ES. by herself? She may hold onto the railing or wall. il tr ‘ 4. Does your child run fairly well, stopping herself without bumping into things or falling? 5. Does your child jump with both feet leaving the floor at the same time? 6. Without holding onto anything for suppert, does your child kick a ball by swinging his leg forward? ves Oo COMMUNICATION TOTAL SOMETIMES Oo O° Oo O° NoTver Oo °o ° GROSS MOTOR TOTAL “if Grose Motor it 1m & is marked "yes" or “sometimes,” mark ‘Gross Motor tem 3 "yea ‘Ages & Stages Quesdonnahee®, Third Eton (ASO3™), Squires & Bricker 101240300 (© 2009 Pau Brookes Publishing Co. Alright served page 30f7(BASQS oe 24 Month Questionnaire poet? FINE MOTOR 1. Does your child get a spoon into his mouth right side up so that the food usually doesn't spill? SOMETIMES N 2. Does your child turn the pages of a book by herself? (She may turn ‘more than one page at a time.) 3. Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars? 4. Does your child flip switches off and on? y ip 0000 Og! 0000 08 | 5, Does your child stack seven small blocks or toys on top of each other by herself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.) oO O° Oo — 6. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace? FINE MOTOR TOTAL = __ PROBLEM SOLVING ves SoMeTMES Nor ver count ye" 1. After watching you draw a line from the top of the BX O oO Oo nw ppaper to the bottom with a crayon (or pencil or pen), <> does your child copy you by drawing a single line on, the paper in any direction? (Mark “not yet” ifyour Count as “not yer child scribbles back and forth.) ARCY 2. After a crumb o¢ Cheerios cropped into a small, clear botl, does ° ° o — your child turn the bottle upside down to Gump out the crumb or Cheerio? (Do not show him how) (You can use'a sode-pop bottle or baby bottle) 3. Does your child pretend objects are something ele? For example, oO fo) oO does your chid hold a cup to her ear pretending tina tlephone? Does the puta box on her head pretending its what? Does she use 9 Bleck orsmall toy toate food? 4. Does your child put things away where they belong? For example, does Oo Oo oO — he knw his toys belong on the toy shelf, his blanket goes on his bed, and dishes go inthe kitchen? 5. IN your child wants something she cannot reach, does she find a chair or Oo Oo o — stand on to reach it for example, to get @ toy on a counter or to you inthe kitchen)? Sige Quests, Td Eton AO. Sars & Ber 101240400 Jo SESS PSAN erase ub Co A igatesonees‘ASQ3) — _ PROBLEM SOLVING | éconnves) ves 4. While your child watches, line up four objects like Oo O° o ~~ blocks or cars in a row. Does your child copy or imitate you and line up four jects in a row? (You can also use spools of thread, small boxes, or other toys.) PROBLEM SOLVING TOTAL _ PERSONAL-SOCIAL ves SOMETMES. 1. Does your child dink rom a cup or glass, putting it down again with ° — lite spiling? 2. Does your child copy the activities you do, such as wipe up a spil, sweep, shave, or comb hair? 3. Does your child eat with a fork? 4, When playing with either a stuffed animal or @ doll, does your child pre- tend to rock it, feed it, change its diapers, put it to bed, and so forth? Oo 00 0 5. Does your child push a little wagon, stroller, o other toy on wheels, steering it around objects and backing out of comers if he cannot tun? 0000 00 ©0000 08 | O° 6. Does your child call herself “I” oF “me” more often than her own name? For example, “I do it,” more often than "Juanita doit." PERSONAL-SOCIALTOTAL = OVERALL Parents and providers may use the space below for additional comments, Ons Ono Do you think your child hears well? If no, expl \ 2. Do you think your child talks like other toddlers her age? If no, explain: Ons Ono 101240500 A008 Pad broke Fooling Co danseOVERALL : - (continued) 3. Can you understand most of what your child says? Hfno, explain: oe Do you think your child walks, runs, and climbs like other toddlers his age? Ifo, explain: Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain: Do you have any concerns about your child's vision? yes, explain: Has your child had any medical problems in the last several months? If yes, explain: ‘Ages & Sisgas Questionnaires, Thi Eton (ASO.37), Squies & Bric 101240600 = ir, Th Eton (ASO.3, Squies & ricker (©2009 Pou H.Brockes Publishing Co. Allighsreserved Ovs Ons Ono24 Month Questionnaire pose7or7 OVERALL fconinves) 8. Do you have any concerns about your child's behavior? If yes, explain: Ow Ono 7 f 9% Does anything about your child worry you? Hf yes, explain: Ovs Ow NS 1 & Sages Qerionae, Ti Eaton (AS0-3Squires rir 101240700 (088 STON aa bred Psahing Co Aligtereones(&ASQ3) 24 Month ASQ-3 Information Summary 7 ”"s9d0s toch Child's name: Date ASQ completed _ Child's 1D #: Date of birth: ‘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 item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total. Inthe chart below, transfer the total scores, and filin the circles corresponding with the total scores. otal eee | catot Communistion | 25.17 Gross Motor | 38.07 Frattotor | 35.16 Problem Soving | 29.78 Personal Socal | 37.54 2, TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up, See ASQ-3 User’s Guide, Chapter 6. 1. Hears well? Yes NO 6. Concems about vision? YES No Comments: Comments: 2. Talks lke other toddlers his age? Yes NO 7. Any medical problems? YES No Comments: Comments: 3. Understand most of what your child says? Yes NO 8 Concerns about behavior? YES No Comments: Comments: 4. Walks, cuns, and climbs ike other toddlers? --Yes_-«NO 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. lf the child's total score is in the [= area, its above the cutoff, and the child's development appears to be on schedule. If the child's total score is in the [3 area, itis close to the cutoff. Provide learning activities and monitor. Ifthe childs total score isin the ml area, itis below the cutoff. Further assessment with a professional may be needed. 4. FOLLOW-UP ACTION TAKEN: Check all that apply. 5. OPTIONAL: Transfe (= YEs, $ X = response missing) Provide activities and rescreen in___ months. Share results with primary healthcare provider Sh Primary health care 1[2]3]4[5]6] Refer for (circle all that apply) hearing, vision, and/or behavioral screening, —_— ‘Communicaion Refer to primary health care provider or other community agency (specify ae reason) _.._ Refer to early intervention/early childhood special education, Erelieed Problem Song ——— No further action taken at this time \n PersnalSoce Other (specify: ‘Age ges Qvtiomaies, Th Eon ASOIY, Sie 8 Ser 101240800 {© ov eat Brookes Publahng Co Aig esored