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ASQ-3 – 16 Month QuestionnaireMichael2021-02-15T17:29:03-06:00

ASQ-3 - 16 MONTH QUESTIONNAIRE

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PATIENT NAME*
DATE OF BIRTH*
FORM COMPLETED BY*
1. Does your child point to, pat, or try to pick up pictures in a book?*
2. Does your child say four or more words in addition to “Mama” and “Dada”?*
3. When your child wants something, does she tell you by pointing to it?*
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.”)*
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.)*
6. Does your child say eight or more words in addition to “Mama” and “Dada”?*
1. Does your child stand up in the middle of the floor by himself and take several steps forward?*
2. Does your child climb onto furniture or other large objects, such as large climbing blocks?*
3. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?*
4. Does your child move around by walking, rather than crawling on her hands and knees?*
5. Does your child walk well and seldom fall?*
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)?*
1. Does your child help turn the pages of a book? (You may lift a page for her to grasp.)*
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.)*
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.)*
4. Does your child stack three small blocks or toys on top of each other by herself?*
5. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?*
6. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)*
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.)*
2. Can your child drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?*
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.)*
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?*
5. Without your showing him how, does your child scribble back and forth when you give him a crayon (or pencil or pen)?*
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.)*
1. Does your child feed himself with a spoon, even though he may spill some food?*
2. Does your child help undress herself by taking off clothes like socks, hat, shoes, or mittens?*
3. Does your child play with a doll or stuffed animal by hugging it?*
4. While looking at himself in the mirror, does your child offer a toy to his own image?*
5. Does your child get your attention or try to show you something by pulling on your hand or clothes?*
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?*
1. Do you think your child hears well?*
2. Do you think your child talks like other toddlers his age?*
3. Can you understand most of what your child says?*
4. Do you think your child walks, runs, and climbs like other toddlers her age?*
5. Does either parent have a family history of childhood deafness or hearing impairment?*
6. Do you have concerns about your child's vision?*
7. Has your child had any medical problems in the last several months?*
8. Do you have any concerns about your child’s behavior?*
9. Does anything about your child worry you?*
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