ASQ-3 (6 Months) DOWNLOAD PDF ASQ-3 (6 Months) ASQ-3 (6 Months) 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:Important Points to Remember:Try each activity with your baby before marking a response.Make completing this questionnaire a game that is fun for you and your baby.Make sure your baby is rested and fed.Please return this questionnaire byCOMMUNICATION1. Does your baby make high-pitched squeals?YESSOMETIMESNOT YET2. When playing with sounds, does your baby make grunting, growling, or other deep-toned sounds?YESSOMETIMESNOT YET3. If you call your baby when you are out of sight, does she look in the direction of your voice?YESSOMETIMESNOT YET4. When a loud noise occurs, does your baby turn to see where the sound came from?YESSOMETIMESNOT YET5. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?YESSOMETIMESNOT YET6. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?YESSOMETIMESNOT YETGROSS MOTOR1. While your baby is on his back, does your baby lift his legs high enough to see his feet?YESSOMETIMESNOT YET2. When your baby is on her tummy, does she straighten both arms and push her whole chest off the bed or floor?YESSOMETIMESNOT YET3. Does your baby roll from his back to his tummy, getting both arms out from under him?YESSOMETIMESNOT YET4. When you put your baby on the floor, does she lean on her hands while sitting? (If she already sits up straight without leaning on her hands, mark “yes” for this item.)YESSOMETIMESNOT YET5. If you hold both hands just to balance your baby, does he support his own weight while standing?YESSOMETIMESNOT YET6. Does your baby get into a crawling position by getting up on her hands and knees?YESSOMETIMESNOT YETFINE MOTOR1. Does your baby grab a toy you offer and look at it, wave it about, or chew on it for about 1 minute?YESSOMETIMESNOT YET2. Does your baby reach for or grasp a toy using both hands at once?YESSOMETIMESNOT YET3. Does your baby reach for a crumb or Cheerio and touch it with his finger or hand? (If he already picks up a small object the size of a pea, mark “yes” for this item.)YESSOMETIMESNOT YET4. Does your baby pick up a small toy, holding it in the center of her hand with her fingers around it?YESSOMETIMESNOT YET5. Does your baby try to pick up a crumb or Cheerio by using his thumb and all of his fingers in a raking motion, even if he isn’t able to pick it up? (If he already picks up the crumb or Cheerio, mark “yes” for this item.)YESSOMETIMESNOT YET6. Does your baby pick up a small toy with only one hand?YESSOMETIMESNOT YETPROBLEM SOLVING1. When a toy is in front of your baby, does she reach for it with both hands?YESSOMETIMESNOT YET2. When your baby is on his back, does he turn his head to look for a toy when he drops it? (If he already picks it up, mark “yes” for this item.)YESSOMETIMESNOT YET3. When your baby is on her back, does she try to get a toy she has dropped if she can see it?YESSOMETIMESNOT YET4. Does your baby pick up a toy and put it in his mouth?YESSOMETIMESNOT YET5. Does your baby pass a toy back and forth from one hand to the other?YESSOMETIMESNOT YET6. Does your baby play by banging a toy up and down on the floor or table?YESSOMETIMESNOT YETPERSONAL-SOCIAL1. When in front of a large mirror, does your baby smile or coo at herself?YESSOMETIMESNOT YET2. Does your baby act differently toward strangers than he does with you and other familiar people? (Reactions to strangers may include staring, frowning, withdrawing, or crying.)YESSOMETIMESNOT YET3. While lying on her back, does your baby play by grabbing her foot?YESSOMETIMESNOT YET4. When in front of a large mirror, does your baby reach out to pat the mirror?YESSOMETIMESNOT YET5. While your baby is on his back, does he put his foot in his mouth?YESSOMETIMESNOT YET6. Does your baby try to get a toy that is out of reach? (She may roll, pivot on her tummy, or crawl to get it.)YESSOMETIMESNOT YETOVERALLParents and providers may use the space below for additional comments1. Does your baby use both hands and both legs equally well? If no, explain:SOMETIMESNOT YET2. When you help your baby stand, are his feet flat on the surface most of the time? If no, explain:SOMETIMESNOT YET3. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:SOMETIMESNOT YET4. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:SOMETIMESNOT YET5. Do you have concerns about your baby’s vision? If yes, explain:SOMETIMESNOT YET6. Has your baby had any medical problems in the last several months? If yes, explain:SOMETIMESNOT YET7. Do you have any concerns about your baby’s behavior? If yes, explain:SOMETIMESNOT YET8. Does anything about your baby worry you? If yes, explain:SOMETIMESNOT YETAges & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved.Submit form
