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ASQ-3 – 16 Month Questionnaire
Michael
2025-09-23T11:28:40-05:00
16 MONTH ASSESSMENT
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MRN
PATIENT NAME
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First
Last
DATE OF BIRTH
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Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
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13
14
15
16
17
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21
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31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1996
1995
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1992
1991
1990
1989
1988
1987
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1974
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1933
1932
1931
1930
1929
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1927
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1925
1924
1923
1922
1921
1920
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Assessment Name
1. Does your child point to, pat, or try to pick up pictures in a book?
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YES
SOMETIMES
NOT YET
2. Does your child say four or more words in addition to “Mama” and “Dada”?
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YES
SOMETIMES
NOT YET
3. When your child wants something, does she tell you by pointing to it?
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YES
SOMETIMES
NOT YET
4. When you ask your child to, does he go into another room to find a familiar toy or object? (You might ask, “Where is your ball?” or say, “Bring me your coat,” or “Go get your blanket.”)
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YES
SOMETIMES
NOT YET
5. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as “Mama eat,” “Daddy play,” “Go home,” or “What’s this?” does your child say both words back to you? (Mark “yes” even if her words are difficult to understand.)
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YES
SOMETIMES
NOT YET
6. Does your child say eight or more words in addition to “Mama” and “Dada”?
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YES
SOMETIMES
NOT YET
1. Does your child stand up in the middle of the floor by himself and take several steps forward?
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YES
SOMETIMES
NOT YET
2. Does your child climb onto furniture or other large objects, such as large climbing blocks?
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YES
SOMETIMES
NOT YET
3. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?
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YES
SOMETIMES
NOT YET
4. Does your child move around by walking, rather than crawling on her hands and knees?
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YES
SOMETIMES
NOT YET
5. Does your child walk well and seldom fall?
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YES
SOMETIMES
NOT YET
6. Does your child climb on an object such as a chair to reach something he wants (for example, to get a toy on a counter or to “help” you in the kitchen)?
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YES
SOMETIMES
NOT YET
1. Does your child help turn the pages of a book? (You may lift a page for her to grasp.)
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YES
SOMETIMES
NOT YET
2. Does your child throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)
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YES
SOMETIMES
NOT YET
3. Does your child 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.)
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YES
SOMETIMES
NOT YET
4. Does your child stack three small blocks or toys on top of each other by herself?
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YES
SOMETIMES
NOT YET
5. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?
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YES
SOMETIMES
NOT YET
6. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)
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YES
SOMETIMES
NOT YET
1. After you scribble back and forth on paper with a crayon (or pencil or pen), does your child copy you by scribbling? (If she already scribbles on her own, mark “yes” for this item.)
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YES
SOMETIMES
NOT YET
2. Can your child drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?
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YES
SOMETIMES
NOT YET
3. Does your child drop several small toys, one after another, into a container like a bowl or box? (You may show him how to do it.)
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YES
SOMETIMES
NOT YET
4. After you have shown your child how, does she try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?
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YES
SOMETIMES
NOT YET
5. Without your showing him how, does your child scribble back and forth when you give him a crayon (or pencil or pen)?
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YES
SOMETIMES
NOT YET
6. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump it out? (You may show her how.)
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YES
SOMETIMES
NOT YET
1. Does your child feed himself with a spoon, even though he may spill some food?
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YES
SOMETIMES
NOT YET
2. Does your child help undress herself by taking off clothes like socks, hat, shoes, or mittens?
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YES
SOMETIMES
NOT YET
3. Does your child play with a doll or stuffed animal by hugging it?
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YES
SOMETIMES
NOT YET
4. While looking at himself in the mirror, does your child offer a toy to his own image?
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YES
SOMETIMES
NOT YET
5. Does your child get your attention or try to show you something by pulling on your hand or clothes?
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YES
SOMETIMES
NOT YET
6. Does your child come to you when she needs help, such as with winding up a toy or unscrewing a lid from a jar?
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YES
SOMETIMES
NOT YET
1. Do you think your child hears well?
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YES
NO
Please explain:
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2. Do you think your child talks like other toddlers his age?
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YES
NO
Please explain:
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3. Can you understand most of what your child says?
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YES
NO
Please explain:
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4. Do you think your child walks, runs, and climbs like other toddlers her age?
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YES
NO
Please explain:
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5. Does either parent have a family history of childhood deafness or hearing impairment?
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YES
NO
Please explain:
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6. Do you have concerns about your child's vision?
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YES
NO
Please explain:
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7. Has your child had any medical problems in the last several months?
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YES
NO
Please explain:
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8. Do you have any concerns about your child’s behavior?
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YES
NO
Please explain:
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9. Does anything about your child worry you?
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YES
NO
Please explain:
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