ASQ-3 - 14 Month Questionnaire

14 MONTH ASSESSMENT

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MRN

PATIENT NAME*

First Last

DATE OF BIRTH*

Month

Day

Year

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Assessment Name

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.)*

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

3. Does your baby shake his head when he means “no” or “yes”?*

YES

SOMETIMES

NOT YET

4. Does your baby point to, pat, or try to pick up pictures in a book?*

YES

SOMETIMES

NOT YET

5. Does your baby say four or more words in addition to “Mama” and “Dada”?*

YES

SOMETIMES

NOT YET

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.”)*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

4. Does your baby climb onto furniture or other large objects, such as large climbing blocks?*

YES

SOMETIMES

NOT YET

5. Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?*

YES

SOMETIMES

NOT YET

6. Does your baby move around by walking, rather than by crawling on his hands and knees?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

5. Does your baby make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?*

YES

SOMETIMES

NOT YET

6. Does your baby stack three small blocks or toys on top of each other by herself?*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

4. Can your baby drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

4. Does your baby feed herself with a spoon, even though she may spill some food?*

YES

SOMETIMES

NOT YET

5. Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?*

YES

SOMETIMES

NOT YET

6. Does your baby get your attention or try to show you something by pulling on your hand or clothes?*

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:*