ASQ-3 (30 Months) DOWNLOAD PDF ASQ-3 (30 Months) ASQ-3 (30 Months) Date ASQ completed:Baby’s informationChild’s first name:Middle initial:Child’s last name:Child’s date of birth:If Child’s 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 baby:ParentGuardianTeacherChild care providerGrandparent or other relativeFoster parentFoster parentOtherCity:State/Province:ZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Virgin IslandsUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis 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. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, “What is this?” does your child correctly name at least one picture?YESSOMETIMESNOT YET2. Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?YESSOMETIMESNOT YET“Put the toy on the table.”“Close the door.”“Bring me a towel.”“Find your coat.”. “Take my hand"“Get your book.”3. When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark “sometimes” if she cor- rectly points to at least three different body parts.)YESSOMETIMESNOT YET4. Does your child make sentences that are three or four words long? Please give an example:YESSOMETIMESNOT YET5. Without giving your child help by pointing or using gestures, ask him to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly?YESSOMETIMESNOT YET6. When looking at a picture book, does your child tell you what is hap- pening or what action is taking place in the picture (for example, “bark- ing,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?”YESSOMETIMESNOT YETGROSS MOTOR1. Does your child run fairly well, stopping herself without bumping into things or falling?YESSOMETIMESNOT YET2. Does your child walk either up or down at least two steps by himself? He may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)YESSOMETIMESNOT YET3. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?YESSOMETIMESNOT YET4. Does your child jump with both feet leaving the floor at the same time?YESSOMETIMESNOT YET5. Does your child walk up stairs, using only one foot on each * stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall.YESSOMETIMESNOT YET6. Does your child stand on one foot for about 1 second without holding onto anything?YESSOMETIMESNOT YETFINE MOTOR1. Does your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?YESSOMETIMESNOT YET2. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction?YESSOMETIMESNOT YET3. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?YESSOMETIMESNOT YET4. After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction?YESSOMETIMESNOT YET5. After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?YESSOMETIMESNOT YET6. Does your child turn pages in a book, one page at a time?YESSOMETIMESNOT YETPROBLEM SOLVING1. When looking in the mirror, ask, “Where is ?” (Use your child’s name.) Does your child point to her image in the mirror?YESSOMETIMESNOT YET2. If your child wants something he cannot reach, does he find a chair or box to stand on to reach it (for example, to get a toy on a counter or to “help” you in the kitchen)?YESSOMETIMESNOT YET3. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.)YESSOMETIMESNOT YET4. When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”) Please write your child’s response here:YESSOMETIMESNOT YET5. When you say, “Say ‘seven three,’” does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, “Say ‘eight two.’” Your child must repeat just one series of two numbers for you to answer “yes” to this question.YESSOMETIMESNOT YET6. After your child draws a “picture,” even a simple scribble, does she tell you what she drew? (You may say, “Tell me about your picture,” or ask, “What is this?” to prompt her.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. If you do any of the following gestures, does your child copy at least one of them?YESSOMETIMESNOT YETOpen and close your mouth.Pull on your earlobe.Blink your eyes.Pat your cheek.2. Does your child use a spoon to feed himself with little spilling?YESSOMETIMESNOT YET3. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she cannot turn?YESSOMETIMESNOT YET4. Does your child put on a coat, jacket, or shirt by himself?YESSOMETIMESNOT YET5. After you put on loose-fitting pants around her feet, does your child pull them completely up to her waist?YESSOMETIMESNOT YET6. When your child is looking in a mirror and you ask, “Who is in the mir- ror?” does he say either “me” or his own name?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 toddlers 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 toddlers 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:YesNoSubmit form
