ASQ-3 (9 Months) DOWNLOAD PDF ASQ-3 (9 Months) ASQ-3 (9 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 sounds like “da,” “ga,” “ka,” and “ba”?YESSOMETIMESNOT YET2. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?YESSOMETIMESNOT YET3. Does your baby make two similar sounds like “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)YESSOMETIMESNOT YET4. If you ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)?YESSOMETIMESNOT YET5. Does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back,” without your using gestures?YESSOMETIMESNOT YET6. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)YESSOMETIMESNOT YETGROSS MOTOR1. If you hold both hands just to balance your baby, does he support his own weight while standing?YESSOMETIMESNOT YET2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?YESSOMETIMESNOT YET3. When you stand your baby next to furniture or the crib rail, does she hold on without leaning her chest against the furniture for support?YESSOMETIMESNOT YET4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?YESSOMETIMESNOT YET5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?YESSOMETIMESNOT YET6. Does your baby walk beside furniture while holding on with only one hand?YESSOMETIMESNOT YETFINE MOTOR1. Does your baby pick up a small toy with only one hand?YESSOMETIMESNOT YET2. Does your baby successfully pick up a crumb or Cheerio by using her thumb and all of her fingers in a raking motion? (If she already picks up a crumb or Cheerio, mark “yes” for this item.)YESSOMETIMESNOT YET3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)YESSOMETIMESNOT YET4. After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (The string may be attached to a toy.)YESSOMETIMESNOT YET5. Does your baby pick up a crumb or Cheerio with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it.YESSOMETIMESNOT YET6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?YESSOMETIMESNOT YETPROBLEM SOLVING1. Does your baby pass a toy back and forth from one hand to the other?YESSOMETIMESNOT YET2. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?YESSOMETIMESNOT YET3. When holding a toy in his hand, does your baby bang it against another toy on the table?YESSOMETIMESNOT YET4. While holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?YESSOMETIMESNOT YET5. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?YESSOMETIMESNOT YET6. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.)YESSOMETIMESNOT YETPERSONAL-SOCIAL1. While your baby is on her back, does she put her foot in her mouth?YESSOMETIMESNOT YET2. Does your baby drink water, juice, or formula from a cup while you hold it?YESSOMETIMESNOT YET3. Does your baby feed himself a cracker or a cookie?YESSOMETIMESNOT YET4. When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn’t let go of it? (If she already lets go of the toy into your hand, mark “yes” for this item.)YESSOMETIMESNOT YET5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?YESSOMETIMESNOT YET6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?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
