ASQ-3 (15 Months) DOWNLOAD PDF ASQ-3 (15 Months) ASQ-3 (15 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 parentFoster parentOtherCity: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: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 byAt this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your baby more than one time. If possible, try the activities when your baby is cooperative. If your baby can do the activity but refuses, mark “yes” for the item.COMMUNICATION1. 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 YET2. When your baby wants something, does she tell you by pointing to it?YESSOMETIMESNOT YET3. Does your baby shake his head when he means “no” or “yes”?YESSOMETIMESNOT YET4. Does your baby point to, pat, or try to pick up pictures in a book?YESSOMETIMESNOT YET5. Does your baby say four or more words in addition to “Mama” and “Dada”?YESSOMETIMESNOT YET6. When you ask her to, does your baby go into another room to find a fa- miliar toy or object? (You might ask, “Where is your ball?” or say, “Bring me your coat,” or “Go get your blanket.”)YESSOMETIMESNOT YETGROSS MOTOR1. 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 YET2. 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 YET3. Does your baby stand up in the middle of the floor by himself and take several steps forward?YESSOMETIMESNOT YET4. Does your baby climb onto furniture or other large objects, such as large climbing blocks?YESSOMETIMESNOT YET5. Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?YESSOMETIMESNOT YET6. Does your baby move around by walking, rather than by crawling on his hands and knees?YESSOMETIMESNOT YETFINE MOTOR1. 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 YET2. Does your baby throw a small ball with a forward arm mo- tion? (If he simply drops the ball, mark “not yet” for this item.)YESSOMETIMESNOT YET3. Does your baby help turn the pages of a book? (You may lift a page for her to grasp.)YESSOMETIMESNOT YET4. Does your baby stack a small block or toy on top of another one? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)YESSOMETIMESNOT YET5. Does your baby make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?YESSOMETIMESNOT YET6. Does your baby stack three small blocks or toys on top of each other by herself?YESSOMETIMESNOT YETPROBLEM SOLVING1. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although he may not let go of it? (If he already lets go of the toy into a bowl or box, mark “yes” for this item.)YESSOMETIMESNOT YET2. Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show her how to do it.)YESSOMETIMESNOT YET3. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If he already scribbles on his own, mark “yes” for this item.)YESSOMETIMESNOT YET4. Can your baby drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?YESSOMETIMESNOT YET5. Does your baby drop several small toys, one after another, into a con- tainer like a bowl or box? (You may show her how to do it.)YESSOMETIMESNOT YET6. After you have shown your baby how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?YESSOMETIMESNOT YETPERSONAL-SOCIAL1. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?YESSOMETIMESNOT YET2. Does your baby roll or throw a ball back to you so that you can return it to him?YESSOMETIMESNOT YET3. Does your baby play with a doll or stuffed animal by hugging it?YESSOMETIMESNOT YET4. Does your baby feed herself with a spoon, even though she may spill some food?YESSOMETIMESNOT YET5. Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?YESSOMETIMESNOT YET6. Does your baby get your attention or try to show you something by pulling on your hand or clothes?YESSOMETIMESNOT YETOVERALLParents and providers may use the space below for additional comments.1. Does your baby move both hands and both legs equally well? If no, explain:yesNo2. Does your baby play with sounds or seem to make words? If no, explain:YesNo3. When your baby is standing, are her feet flat on the surface most of the time? If no, explain:YesNo4. Do you have concerns that your baby is too quiet or does not make sounds like other babies do? If yes, explain:YesNo5. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:YesNo6. Do you have concerns about your baby’s vision? If yes, explain:YesNo7. Has your baby had any medical problems in the last several months? If yes, explain:YesNo8. Do you have any concerns about your baby’s behavior? If yes, explain:YesNo9. Does anything about your baby worry you? If yes, explain:YesNoSubmit form
