ASQ-3 (18 Months) DOWNLOAD PDF ASQ-3 (18 Months) ASQ-3 (18 Months) Date ASQ completed:Baby’s informationChild’s first name:Middle initial:Child’s last name:Child’s date of birth:If baby was born 3 or more weeks prematurely, # of weeks premature:Child’s gender:MaleFemalePerson filling out questionnaireFirst name:Middle initialLast name:Street address:Relationship to child: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 INFORMATIONChild 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 child 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. When your child wants something, does she tell you by pointing to it?YESSOMETIMESNOT YET2. When you ask your child to, does he 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 YET3. Does your child say eight or more words in addition to “Mama” and “Dada”?YESSOMETIMESNOT YET4. 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 YET5. 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?” (He needs to identify only one picture correctly.)YESSOMETIMESNOT YET6. 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 YETGROSS MOTOR1. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?YESSOMETIMESNOT YET2. Does your child move around by walking, rather than by crawling on her hands and knees?YESSOMETIMESNOT YET3. Does your child walk well and seldom fall?YESSOMETIMESNOT YET4. Does your child climb on an object such as a chair to reach something he wants (for example, to get a toy on a counter or to “help” you in the kitchen)?YESSOMETIMESNOT YET5. 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 YET6. 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 YETFINE MOTOR1. Does your child throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)YESSOMETIMESNOT YET2. Does your child 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 YET3. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?YESSOMETIMESNOT YET4. Does your child stack three small blocks or toys on top of each other by himself?YESSOMETIMESNOT YET5. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)YESSOMETIMESNOT YET6. Does your child get a spoon into her mouth right side up so that the food usually doesn’t spill?YESSOMETIMESNOT YETPROBLEM SOLVING1. Does your child drop several small toys, one after another, into a con- tainer like a bowl or box? (You may show him how to do it.)YESSOMETIMESNOT YET2. After you have shown your child how, does she try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?YESSOMETIMESNOT YET3. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle over to dump it out? (You may show him how.) (You can use a soda-pop bottle or a baby bottle.)YESSOMETIMESNOT YET4. Without your showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)?YESSOMETIMESNOT YET5. 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 YET6. 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.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. While looking at herself in the mirror, does your child offer a toy to her own image?YESSOMETIMESNOT YET2. Does your child play with a doll or stuffed animal by hugging it?YESSOMETIMESNOT YET3. Does your child get your attention or try to show you something by pulling on your hand or clothes?YESSOMETIMESNOT YET4. Does your child come to you when he needs help, such as with winding up a toy or unscrewing a lid from a jar?YESSOMETIMESNOT YET5. Does your child drink from a cup or glass, putting it down again with little spilling?YESSOMETIMESNOT YET6. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?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 his 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 her 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 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:YesNoSubmit form
