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ASQ-3 – 14 Month QuestionnaireMichael2021-02-15T17:28:29-06:00

ASQ-3 - 14 MONTH QUESTIONNAIRE

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PATIENT NAME*
DATE OF BIRTH*
FORM COMPLETED BY*
1. 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.)*
2. When your baby wants something, does she tell you by pointing to it?*
3. Does your baby shake his head when he means “no” or “yes”?*
4. Does your baby point to, pat, or try to pick up pictures in a book?*
5. Does your baby say four or more words in addition to “Mama” and “Dada”?*
6. When you ask her to, does your baby go into another room to find a fa- miliar toy or object? (You might ask, “Where is your ball?” or say, “Bring me your coat,” or “Go get your blanket.”)*
1. 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.)*
2. 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.)*
3. Does your baby stand up in the middle of the floor by himself and take several steps forward?*
4. Does your baby climb onto furniture or other large objects, such as large climbing blocks?*
5. Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?*
6. Does your baby move around by walking, rather than by crawling on his hands and knees?*
1. 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?*
2. Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)*
3. Does your baby help turn the pages of a book? (You may lift a page for her to grasp.)*
4. Does your baby stack a small block or toy on top of another one? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)*
5. Does your baby make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?*
6. Does your baby stack three small blocks or toys on top of each other by herself?*
1. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although he may not let go of it? (If he already lets go of the toy into a bowl or box, mark “yes” for this item.)*
2. Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show her how to do it.)*
3. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If he already scribbles on his own, mark “yes” for this item.)*
4. Can your baby drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?*
5. Does your baby drop several small toys, one after another, into a container like a bowl or box? (You may show her how to do it.)*
6. After you have shown your baby how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?*
1. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?*
2. Does your baby roll or throw a ball back to you so that you can return it to him?*
3. Does your baby play with a doll or stuffed animal by hugging it?*
4. Does your baby feed herself with a spoon, even though she may spill some food?*
5. Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?*
6. Does your baby get your attention or try to show you something by pulling on your hand or clothes?*
1. Does your baby use both hands and both legs equally well?*
2. Does your baby play with sounds or seem to make words?*
3. When your baby is standing, are her feet flat on the surface most of the time?*
4. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*
5. Does either parent have a family history of childhood deafness or hearing impairment?*
6. Do you have concerns about your baby’s vision*
7. Has your baby had any medical problems in the last several months?*
8. Do you have any concerns about your baby’s behavior?*
9. Does anything about your baby worry you?*
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