ASQ-3 (2 Months) DOWNLOAD PDF ASQ-3 (2 Months) ASQ-3(2Months) 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:Try each activity with your baby before marking a response.Make sure your baby is rested and fed.Make completing this questionnaire a game that is fun for you and your baby.Please return this questionnaire byCOMMUNICATION1. Does your baby sometimes make throaty or gurgling sounds?YESSOMETIMESNOT YET2. Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?YESSOMETIMESNOT YET3. When you speak to your baby, does she make sounds back to you?YESSOMETIMESNOT YET4. Does your baby smile when you talk to him?YESSOMETIMESNOT YET5. Does your baby chuckle softly?YESSOMETIMESNOT YET6. After you have been out of sight, does your baby smile or get excited when she sees you?YESSOMETIMESNOT YETGROSS MOTOR1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?YESSOMETIMESNOT YET2. When your baby is on her tummy, does she turn her head to the side?YESSOMETIMESNOT YET3. When your baby is on his tummy, does he hold his head up longer than a few seconds?YESSOMETIMESNOT YET4. When your baby is on her back, does she kick her legs?YESSOMETIMESNOT YET5. While your baby is on his back, does he move his head from side to side?YESSOMETIMESNOT YET6. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?YESSOMETIMESNOT YETFINE MOTOR1. Is your baby’s hand usually tightly closed when he is awake? (If your baby used to do this but no longer does, mark “yes.”)YESSOMETIMESNOT YET2. Does your baby grasp your finger if you touch the palm of her hand?YESSOMETIMESNOT YET3. When you put a toy in his hand, does your baby hold it in his hand briefly?YESSOMETIMESNOT YET4. Does your baby touch her face with her hands?YESSOMETIMESNOT YET5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?YESSOMETIMESNOT YET6. Does your baby grab or scratch at her clothes?YESSOMETIMESNOT YETPROBLEM SOLVING1. Does your baby look at objects that are 8–10 inches away?YESSOMETIMESNOT YET2. When you move around, does your baby follow you with his eyes?YESSOMETIMESNOT YET3. When you move a toy slowly from side to side in front of your baby’s face (about 10 inches away), does your baby follow the toy with her eyes, sometimes turning her head?YESSOMETIMESNOT YET4. When you move a small toy up and down slowly in front of your baby’s face (about 10 inches away), does your baby follow the toy with his eyes?YESSOMETIMESNOT YET5. When you hold your baby in a sitting position, does she look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?YESSOMETIMESNOT YET6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?YESSOMETIMESNOT YETPERSONAL-SOCIAL1. Does your baby sometimes try to suck, even when she’s not feeding?YESSOMETIMESNOT YET2. Does your baby cry when he is hungry, wet, tired, or wants to be held?YESSOMETIMESNOT YET3. Does your baby smile at you?YESSOMETIMESNOT YET4. When you smile at your baby, does she smile back?YESSOMETIMESNOT YET5. Does your baby watch his hands?YESSOMETIMESNOT YET6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?YESSOMETIMESNOT YETOVERALLParents and providers may use the space below for additional comments1. Did your baby pass the newborn hearing screening test? If no, explain:YesNo2. Does your baby move both hands and both legs equally well? If no, explain:YesNo3. Does either parent have a family history of childhood deafness, hearing impairment, or vision problems? If yes, explain:YesNo4. Has your baby had any medical problems? If yes, explain:YesNo5. Do you have concerns about your baby’s behavior (for example, eating, sleeping)? If yes, explain:YesNo6. Does anything about your baby worry you? If yes, explain:YesNoSubmit form
