ASQ-3 (12 Months) DOWNLOAD PDF ASQ-3 (12 Months) ASQ-3(12 Months) Date ASQ completed:Baby’s informationBaby’s first name:Middle initial:Baby’s last name:Baby’s date of birth:If baby was born 3 or more weeks prematurely, # of weeks premature: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 BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited 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 #:Age at administration, in month and days:Program ID #:If premature, adjust age, in month and days:Program name: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 byCOMMUNICATION1. Does your baby make two similar sounds, such as “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)YESSOMETIMESNOT YET2. If you ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)?YESSOMETIMESNOT YET3. Does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back,” without your using gestures?YESSOMETIMESNOT YET4. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)YESSOMETIMESNOT YET5. When you ask, “Where is the ball (hat, shoe, etc.)?” does your baby look at the object? (Make sure the object is present. Mark “yes” if she knows one object.)YESSOMETIMESNOT YET6. When your baby wants something, does he tell you by pointing to it?YESSOMETIMESNOT YETGROSS MOTOR1. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?YESSOMETIMESNOT YET2. While holding onto furniture, does your baby lower herself with control (without falling or flopping down)?YESSOMETIMESNOT YET2. While holding onto furniture, does your baby lower herself with control (without falling or flopping down)?YESSOMETIMESNOT YET4. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark “yes” for this item.)YESSOMETIMESNOT YET5. When you hold one hand just to balance your baby, does she take several steps forward? (If your baby already walks alone, mark “yes” for this item.)YESSOMETIMESNOT YET6. Does your baby stand up in the middle of the floor by himself and take several steps forward?YESSOMETIMESNOT YETFINE MOTOR1. After one or two tries, does your baby pick up a piece of string with his first finger and thumb? (The string may be attached to a toy.)YESSOMETIMESNOT YET2. Does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger? She may rest her arm or hand on the table while doing it.YESSOMETIMESNOT YET3. Does your baby put a small toy down, without dropping it, and then take his hand off the toy?YESSOMETIMESNOT YET4. Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?YESSOMETIMESNOT YET5. Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)YESSOMETIMESNOT YET6. Does your baby help turn the pages of a book? (You may lift a page for him to grasp.)YESSOMETIMESNOT YETPROBLEM SOLVING1. When holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?YESSOMETIMESNOT YET2. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?YESSOMETIMESNOT YET3. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.)YESSOMETIMESNOT YET4. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although she may not let go of it? (If she already lets go of the toy into a bowl or box, mark “yes” for this item.)YESSOMETIMESNOT YET5. Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show him how to do it.)YESSOMETIMESNOT YET6. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If she already scribbles on her own, mark “yes” for this item.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. When you hold out your hand and ask for his toy, does your baby offer it to you even if he doesn’t let go of it? (If he already lets go of the toy into your hand, mark “yes” for this item.)YESSOMETIMESNOT YET2. When you dress your baby, does she push her arm through a sleeve once her arm is started in the hole of the sleeve?YESSOMETIMESNOT YET3. When you hold out your hand and ask for his toy, does your baby let go of it into your hand?YESSOMETIMESNOT YET4. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?YESSOMETIMESNOT YET5. Does your baby roll or throw a ball back to you so that you can return it to him?YESSOMETIMESNOT YET6. Does your baby play with a doll or stuffed animal by hugging it?YESSOMETIMESNOT YETOVERALLParents and providers may use the space below for additional comments1. Does your baby use both hands and both legs equally well? If no, explain:SOMETIMESNOT YET2. Does your baby play with sounds or seem to make words? If no, explain:SOMETIMESNOT YET3. When your baby is standing, are her feet flat on the surface most of the time? If no, explain:SOMETIMESNOT YET4. Do you have concerns that your baby is too quiet or does not make sounds like other babies do? If yes, explain:SOMETIMESNOT YET5. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:SOMETIMESNOT YET6. Do you have concerns about your baby’s vision? If yes, explain:SOMETIMESNOT YET7. Has your baby had any medical problems in the last several months? If yes, explain:SOMETIMESNOT YET8. Do you have any concerns about your baby’s behavior? If yes, explain:SOMETIMESNOT YET9. Does anything about your baby worry you? If yes, explain:SOMETIMESNOT YETAges & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved.Submit form
