ASQ-3 (36 Months) DOWNLOAD PDF ASQ-3 (36 Months) ASQ-3 (36 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. 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 YET2. Does your child make sentences that are three or four words long? Please give an example:YESSOMETIMESNOT YET3. 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 YET4. 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 YET5. Show your child how a zipper on a coat moves up and down, and say, “See, this goes up and down.” Put the zipper to the middle and ask your child to move the zipper down. Return the zipper to the middle and ask your child to move the zipper up. Do this several times, placing the zipper in the middle before asking your child to move it up or down. Does your child consistently move the zipper up when you say “up” and down when you say “down”?YESSOMETIMESNOT YET6. When you ask, “What is your name?” does your child say both her first and last names?YESSOMETIMESNOT YETGROSS MOTOR1. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?YESSOMETIMESNOT YET2. Does your child jump with both feet leaving the floor at the same time?YESSOMETIMESNOT YET3. 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. (You can look for this at a store, on a playground, or at home.)YESSOMETIMESNOT YET4. Does your child stand on one foot for about 1 second without holding onto anything?YESSOMETIMESNOT YET5. While standing, does your child throw a ball overhand by raising his arm to shoulder height and throwing the ball forward? (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)YESSOMETIMESNOT YET6. Does your child jump forward at least 6 inches with both feet leaving the ground at the same time?YESSOMETIMESNOT YETFINE MOTOR1. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, 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 vertical direction?YESSOMETIMESNOT YET2. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?YESSOMETIMESNOT YET3. 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 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. Does your child try to cut paper with child-safe scissors? He does not need to cut the paper but must get the blades to open and close while holding the paper with the other hand. (You may show your child how to use scissors. Carefully watch your child’s use of scissors for safety reasons.)YESSOMETIMESNOT YETWhen drawing, does your child hold a pencil, crayon, or pen between her fingers and thumb like an adult doesYESSOMETIMESNOT YETPROBLEM SOLVING1. 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 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. 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 YET4. 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 YET5. Show your child how to make a bridge with blocks, boxes, or cans, like the example. Does your child copy you by making one like it?YESSOMETIMESNOT YET6. When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If neces- sary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers for you to answer “yes” to this question.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. Does your child use a spoon to feed herself with little spilling?YESSOMETIMESNOT YET2. Does your child push a little wagon, stroller, or toy on wheels, steering it around objects and backing out of corners if he cannot turn?YESSOMETIMESNOT YET3. When your child is looking in a mirror and you ask, “Who is in the mir- ror?” does she say either “me” or her own name?YESSOMETIMESNOT YET4. Does your child put on a coat, jacket, or shirt by himself?YESSOMETIMESNOT YET5. Using these exact words, ask your child, “Are you a girl or a boy?” Does your child answer correctly?YESSOMETIMESNOT YET6. Does your child take turns by waiting while another child or adult takes a turn?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:YesNoSubmit form
