ASQ-3 - 12 Month Questionnaire

12 MONTH ASSESSMENT

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PATIENT NAME*

First Last

DATE OF BIRTH*

Month

Day

Year

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MRN

1. Does your baby make two similar sounds, such as “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)*

YES

SOMETIMES

NOT YET

2. 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”)?*

YES

SOMETIMES

NOT YET

3. Does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back,” without your using gestures?*

YES

SOMETIMES

NOT YET

4. 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.)*

YES

SOMETIMES

NOT YET

5. When you ask, “Where is the ball (hat, shoe, etc.)?” does your baby look at the object? (Make sure the object is present. Mark “yes” if she knows one object.)*

YES

SOMETIMES

NOT YET

6. When your baby wants something, does he tell you by pointing to it?*

YES

SOMETIMES

NOT YET

1. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?*

YES

SOMETIMES

NOT YET

2. While holding onto furniture, does your baby lower herself with control (without falling or flopping down)?*

YES

SOMETIMES

NOT YET

3. Does your baby walk beside furniture while holding on with only one hand?*

YES

SOMETIMES

NOT YET

4. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark “yes” for this item.)*

YES

SOMETIMES

NOT YET

5. When you hold one hand just to balance your baby, does she take several steps forward? (If your baby already walks alone, mark “yes” for this item.)*

YES

SOMETIMES

NOT YET

6. Does your baby stand up in the middle of the floor by himself and take several steps forward?*

YES

SOMETIMES

NOT YET

1. After one or two tries, does your baby pick up a piece of string with his first finger and thumb? (The string may be attached to a toy.)*

YES

SOMETIMES

NOT YET

2. Does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger? She may rest her arm or hand on the table while doing it.*

YES

SOMETIMES

NOT YET

3. Does your baby put a small toy down, without dropping it, and then take his hand off the toy?*

YES

SOMETIMES

NOT YET

4. Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?*

YES

SOMETIMES

NOT YET

5. Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)*

YES

SOMETIMES

NOT YET

6. Does your baby help turn the pages of a book? (You may lift a page for him to grasp.)*

YES

SOMETIMES

NOT YET

1. When holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?*

YES

SOMETIMES

NOT YET

2. 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)?*

YES

SOMETIMES

NOT YET

3. 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.)*

YES

SOMETIMES

NOT YET

4. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although she may not let go of it? (If she already lets go of the toy into a bowl or box, mark “yes” for this item.)*

YES

SOMETIMES

NOT YET

5. Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show him how to do it.)*

YES

SOMETIMES

NOT YET

6. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If she already scribbles on her own, mark “yes” for this item.)*

YES

SOMETIMES

NOT YET

1. When you hold out your hand and ask for his toy, does your baby offer it to you even if he doesn’t let go of it? (If he already lets go of the toy into your hand, mark “yes” for this item.)*

YES

SOMETIMES

NOT YET

2. When you dress your baby, does she push her arm through a sleeve once her arm is started in the hole of the sleeve?*

YES

SOMETIMES

NOT YET

3. When you hold out your hand and ask for his toy, does your baby let go of it into your hand?*

YES

SOMETIMES

NOT YET

4. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?*

YES

SOMETIMES

NOT YET

5. Does your baby roll or throw a ball back to you so that you can return it to him?*

YES

SOMETIMES

NOT YET

6. Does your baby play with a doll or stuffed animal by hugging it?*

YES

SOMETIMES

NOT YET

1. Does your baby use both hands and both legs equally well?*

YES

Please explain:*

2. Does your baby play with sounds or seem to make words?*

YES

Please explain:*

3. When your baby is standing, are her feet flat on the surface most of the time?*

YES

Please explain:*

4. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*

YES

Please explain:*

5. Does either parent have a family history of childhood deafness or hearing impairment?*

YES

Please explain:*

6. Do you have concerns about your baby’s vision*

YES

Please explain:*

7. Has your baby had any medical problems in the last several months?*

YES

Please explain:*

8. Do you have any concerns about your baby’s behavior?*

YES

Please explain:*

9. Does anything about your baby worry you?*

YES

Please explain:*