ASQ-3 (48 Months) DOWNLOAD PDF ASQ-3 (48 Months) ASQ-3 (48 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. Does your child name at least three items from a common category? For example, if you say to your child, “Tell me some things that you can eat,” does your child answer with something like “cookies, eggs, and cereal”? Or if you say, “Tell me the names of some animals,” does your child answer with something like “cow, dog, and elephant”?YESSOMETIMESNOT YET2. Does your child answer the following questions? (Mark “sometimes” if your child answers only one question.)YESSOMETIMESNOT YET“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:“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:3. Does your child tell you at least two things about common objects? For example, if you say to your child, “Tell me about your ball,” does she say something like, “It’s round. I throw it. It’s big”?YESSOMETIMESNOT YET4. Does your child use endings of words, such as “-s,” “-ed,” and “-ing”? For example, does your child say things like, “I see two cats,” “I am playing,” or “I kicked the ball”?YESSOMETIMESNOT YET5. Without your giving help by pointing or repeating, does your child fol- low 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 YET6. Does your child use all of the words in a sentence (for example, “a,” “the,” “am,” “is,” and “are”) to make complete sentences, such as “I am going to the park,” or “Is there a toy to play with?” or “Are you coming, too?”YESSOMETIMESNOT YETGROSS MOTOR1. 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 YET2. Does your child climb the rungs of a ladder of a playground slide and slide down without help?YESSOMETIMESNOT YET3. 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 YET4. Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?YESSOMETIMESNOT YET5. Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together?YESSOMETIMESNOT YET6. 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 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 YET2. Using child-safe scissors, does your child cut a 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 YET3.Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.)YESSOMETIMESNOT YETL + I O4. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll’s clothing.)YESSOMETIMESNOT YET6. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.)YESSOMETIMESNOT YETPROBLEM SOLVING1. 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 to answer “yes” to this question.)YESSOMETIMESNOT YET2. When asked, “Which circle is the smallest?” does your child point to the smallest circle? (Ask this question without providing help by point- ing, gesturing, or looking at the smallest circle.)YESSOMETIMESNOT YETo O o3. Without your giving help by pointing, does your child follow three dif- ferent directions using the words “under,” “between,” and “middle”? For example, ask your child to put the shoe “under the couch.” Then ask her to put the ball “between the chairs” and the book “in the middle of the table.”YESSOMETIMESNOT YET4. 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 YET5. Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.YESSOMETIMESNOT YET6. If you place five objects in front of your child, can he count them by saying, “one, two, three, four, five,” in order? (Ask this question without providing help by pointing, gesturing, or naming.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. Does your child serve herself, 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 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 number3. Does your child wash his hands using soap and water and dry off with a towel without help?YESSOMETIMESNOT YET4. Does your child tell you the names of two or more playmates, not in- cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)YESSOMETIMESNOT YET5. Does your child brush her teeth by putting toothpaste on the tooth- brush and brushing all of her teeth without help? (You may still need to check and rebrush your child’s teeth.)YESSOMETIMESNOT YET6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?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
