ASQ-3 (24 Months) DOWNLOAD PDF ASQ-3 (24 Months) ASQ-3 (24 Months) Date ASQ completed:Baby’s informationBaby’s first name:Middle initial:Baby’s last name:Baby’s date of birth:Baby’s gender:MaleFemalePerson filling out questionnaireFirst name:Middle initialLast name:Street address:Relationship to baby:ParentGuardianTeacherChild care providerGrandparent or other relativeFoster parentOther:City:State/Province:ZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweHome telephone number:Other telephone number:E-mail address:Names of people assisting in questionnaire completion:PROGRAM INFORMATIONBaby ID #:Program ID #:Program name:On the following pages are questions about activities 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 fill in the circle that indicates whether your child is doing the activity regularly, sometimes, or not yet.Important Points to Remember:Try each activity with your baby before marking a response.Make completing this questionnaire a game that is fun for you and your baby.Make sure your baby is rested and fed.Please return this questionnaire byPlease return this questionnaire byNotes: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.COMMUNICATION1. Without your showing him, does your child point to the correct picture when you say, “Show me the kitty,” or ask, “Where is the dog?” (She needs to identify only one picture correctly.)YESSOMETIMESNOT YET2. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as “Mama eat,” “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.)YESSOMETIMESNOT YET3.Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?YESSOMETIMESNOT YET“Put the toy on the table.”“Close the door.”“Bring me a towel.”“Find your coat.”“Take my hand.”“Get your book.”4. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, “What is this?” does your child correctly name at least one picture?YESSOMETIMESNOT YET5. Does your child say two or three words that represent different ideas together, such as “See dog,” “Mommy come home,” or “Kitty gone”? (Don’t count word combinations that express one idea, such as “bye- bye,” “all gone,” “all right,” and “What’s that?”) Please give an ex- ample of your child’s word combinations:YESSOMETIMESNOT YETNotes:6. Does your child correctly use at least two words like “me,” “I,” “mine,” and “you”?YESSOMETIMESNOT YETGROSS MOTOR1. Does your child walk down stairs 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 a playground, or at home.)YESSOMETIMESNOT YET2. 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? (If your child already kicks a ball, mark “yes” for this item.)YESSOMETIMESNOT YET3. Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wall.YESSOMETIMESNOT YET4. Does your child run fairly well, stopping herself without bumping into things or falling?YESSOMETIMESNOT YET5. Does your child jump with both feet leaving the floor at the same time?YESSOMETIMESNOT YET6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?YESSOMETIMESNOT YETFINE MOTOR1. Does your child get a spoon into his mouth right side up so that the food usually doesn’t spill?YESSOMETIMESNOT YET2. Does your child turn the pages of a book by herself? (She may turn more than one page at a time.)YESSOMETIMESNOT YET3. 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?YESSOMETIMESNOT YET4. Does your child flip switches off and on?YESSOMETIMESNOT YET5. 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.)YESSOMETIMESNOT YET6. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?YESSOMETIMESNOT YETPROBLEM SOLVING1. After watching you draw a line from the top of the paper 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” if your child scribbles back and forth.)YESSOMETIMESNOT YET2. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump out the crumb or Cheerio? (Do not show him how.) (You can use a soda-pop bottle or baby bottle.)YESSOMETIMESNOT YET3. Does your child pretend objects are something else? For example, does your child hold a cup to her ear, pretending it is a telephone? Does she put a box on her head, pretending it is a hat? Does she use a block or small toy to stir food?YESSOMETIMESNOT YET4. Does your child put things away where they belong? For example, does he know his toys belong on the toy shelf, his blanket goes on his bed, and dishes go in the kitchen?YESSOMETIMESNOT YET5. If your child wants something she cannot reach, does she find a chair or box to stand on to reach it (for example, to get a toy on a counter or to “help” you in the kitchen)?YESSOMETIMESNOT YET6. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. Does your child drink from a cup or glass, putting it down again with little spilling?YESSOMETIMESNOT YET2. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?YESSOMETIMESNOT YET3. Does your child eat with a fork?YESSOMETIMESNOT YET4. When playing with either a stuffed animal or a doll, does your child pre- tend to rock it, feed it, change its diapers, put it to bed, and so forth?YESSOMETIMESNOT YET5. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if he cannot turn?YESSOMETIMESNOT YET6. Does your child call herself “I” or “me” more often than her own name? For example, “I do it,” more often than “Juanita do it.”YESSOMETIMESNOT YETOVERALLParents and providers may use the space below for additional comments1. Do you think your child hears well? If no, explain:YESNO2. Do you think your child talks like other toddlers her age? If no, explain:YESNO3. Can you understand most of what your child says? If no, explain:YESNO4. Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain:YESNO5. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:YESNO6. Do you have any concerns about your child’s vision? If yes, explain:YESNO7. Has your child had any medical problems in the last several months? If yes, explain:YESNO8. Do you have any concerns about your child’s behavior? If yes, explain:YESNO9: Does anything about your child worry you? If yes, explain:YESNOAges & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved.Submit form
