ASQ-3 (60 Months) DOWNLOAD PDF ASQ-3 (60 Months) ASQ-3 (60 Months) Date ASQ completed:Baby’s informationChild’s first name:Middle initial:Child’s last name:Child’s date of birth:Child’s gender:MaleFemalePerson filling out questionnaireFirst name:Middle initialLast name:Street address:Relationship to Child:ParentGuardianTeacherChild care providerGrandparent or other relativeFoster 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 INFORMATIONChild ID #:Program ID #: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 child.Make sure your child is rested and fed.Please return this questionnaire byCOMMUNICATION1. Without your giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, “Clap your hands, walk to the door, and sit down,” or “Give me the pen, open the book, and stand up.”YESSOMETIMESNOT YET2. Does your child use four- and five-word sentences? For example, does your child say, “I want the car”? Please write an example:YESSOMETIMESNOT YET3. When talking about something that already happened, does your child use words that end in “-ed,” such as “walked,” “jumped,” or “played”? Ask your child questions, such as “How did you get to the store?” (“We walked.”) “What did you do at your friend’s house?” (“We played.”) Please write an example:YESSOMETIMESNOT YET4. Does your child use comparison words, such as “heavier,” “stronger,” or “shorter”? Ask your child questions, such as “A car is big, but a bus is ” (bigger); “A cat is heavy, but a man is ” (heavier); “A TV is small, but a book is ” (smaller). Please write an example:YESSOMETIMESNOT YET5. Does your child answer the following questions? (Mark “sometimes” if your child answers only one question.) “What do you do when you are hungry?” (Acceptable answers include “get food,” “eat,” “ask for something to eat,” and “have a snack.”) Please write your child’s response:YESSOMETIMESNOT YET“What do you do when you are tired?” (Acceptable answers include: “take a nap,” “rest,” “go to sleep,” “go to bed,” “lie down,” and “sit down.”) Please write your child’s response:6. Does your child repeat the sentences shown below back to you, with- out any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark “yes” if your child repeats both sen- tences without mistakes or “sometimes” if your child repeats one sen- tence without mistakes.)YESSOMETIMESNOT YETJane hides her shoes for Maria to find. Al read the blue book under his bed.GROSS MOTOR1. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)YESSOMETIMESNOT YET2. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)YESSOMETIMESNOT YET3. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)YESSOMETIMESNOT YET4. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)YESSOMETIMESNOT YET5. Does your child hop forward on one foot for a distance of 4–6 feet without putting down the other foot? (You may give her two tries on each foot. Mark “sometimes” if she can hop on one foot only.)YESSOMETIMESNOT YET6. Does your child skip using alternating feet? (You may show him how to do this.)YESSOMETIMESNOT YETFINE MOTOR1. Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)YESSOMETIMESNOT YET(Space for child’s shapes)2. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, “Draw a picture of a girl or a boy.” If your child draws a person with head, body, arms, and legs, mark “yes.” If your child draws a person with only three parts (head, body, arms, or legs), mark “sometimes.” If your child draws a person with two or fewer parts (head, body, arms, or legs), mark “not yet.” Be sure to include the sheet of paper with your child’s drawing with this questionnaire.YESSOMETIMESNOT YET3. Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.)YESSOMETIMESNOT YET4. Using the shapes below to look at, does your child copy the shapes in the space below without tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size. Mark “yes” if she copies all three shapes; mark “sometimes” if your child copies two shapes.)YESSOMETIMESNOT YET(Space for child’s shapes)5. Using the letters below to look at, does your child copy the letters without tracing? Cover up all of the letters except the letter being copied. (Mark “yes” if your child copies four of the letters and you can read them. Mark “sometimes” if your child copies two or three letters and you can read them.)YESSOMETIMESNOT YET(Space for child’s shapes)6. Print your child’s first name. Can your child copy the letters? The letters may be large, backward, or reversed. (Mark “sometimes” if your child copies about half of the letters.)YESSOMETIMESNOT YETSpace for adult’s printing)(Space for child’s printing)PROBLEM SOLVING1. When asked, “Which circle is smallest?” does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)YESSOMETIMESNOT YET2. When shown objects and asked, “What color is this?” does your child name five different colors like red, blue, yellow, orange, black, white, or pink? (Mark “yes” only if your child answers the question correctly using five colors.)YESSOMETIMESNOT YET3. Does your child count up to 15 without making mistakes? If so, mark “yes.” If your child counts to 12 without making mistakes, mark “sometimes.”YESSOMETIMESNOT YET4. Does your child finish the following sentences using a word that means the opposite of the word that is italicized? For example: “A rock is hard, and a pillow is soft.”YESSOMETIMESNOT YETPlease write your child’s responses below:A cow is big, and a mouse isIce is cold, and fire isWe see stars at night, and we see the sun during theWhen I throw the ball up, it comes(Mark “yes” if he finishes three of four sentences correctly. Mark “sometimes” if he finishes two of four sentences correctly.)5. Does your child know the names of numbers? (Mark “yes” if she identi- fies the three numbers below. Mark “sometimes” if she identifies two numbers.)YESSOMETIMESNOT YET3 2 16. Does your child name at least four letters in her name? Point to the let- ters and ask, “What letter is this?” (Point to the letters out of order.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. Can your child serve himself, taking food from one container to an- other, using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?YESSOMETIMESNOT YET2. Does your child wash her hands and face using soap and water and dry off with a towel without help?YESSOMETIMESNOT YET3. Does your child tell you at least four of the following? Please mark the items your child knows.YESSOMETIMESNOT YETFirst nameAgeCity she lives inCity she lives inBoy or girlTelephone number4. Does your child dress and undress himself, including buttoning medium-size buttons and zipping front zippers?YESSOMETIMESNOT YET5. Does your child use the toilet by herself? (She goes to the bathroom, sits on the toilet, wipes, and flushes.) Mark “yes” even if she does this after you remind her.YESSOMETIMESNOT YET6. Does your child usually take turns and share with other children?YESSOMETIMESNOT YETOVERALLParents and providers may use the space below for additional comments.1. Do you think your child hears well? If no, explain:yesNo2. Do you think your child talks like other children her age? If no, explain:YesNo3. Can you understand most of what your child says? If no, explain:YesNo4. Can other people understand most of what your child says? If no, explain:YesNo5. Do you think your child walks, runs, and climbs like other children his age? If no, explain:YesNo6. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:YesNo7. Do you have any concerns about your child’s vision? If yes, explain:YesNo8. Has your child had any medical problems in the last several months? If yes, explain:YesNo9. Do you have any concerns about your child’s behavior? If yes, explain:YesNo10. Does anything about your child worry you? If yes, explain:YesNoSend Message
