ASQ-3 - 16 Month Questionnaire - Pediatric People

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

ASQ-3 - 16 MONTH QUESTIONNAIRE

1PATIENT INFO

2COMMUNICATION

3GROSS MOTOR

4FINE MOTOR

5PROBLEM SOLVING

6PERSONAL - SOCIAL

7OVERALL

PATIENT NAME*
First Last
DATE OF BIRTH*
Month
Day
Year
FORM COMPLETED BY*
First Last

1. Does your child point to, pat, or try to pick up pictures in a book?*
- YES
- SOMETIMES
- NOT YET
2. Does your child say four or more words in addition to “Mama” and “Dada”?*
- YES
- SOMETIMES
- NOT YET
3. When your child wants something, does she tell you by pointing to it?*
- 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.”)*
- 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.)*
- YES
- SOMETIMES
- NOT YET
6. Does your child say eight or more words in addition to “Mama” and “Dada”?*
- YES
- SOMETIMES
- NOT YET

1. Does your child stand up in the middle of the floor by himself and take several steps forward?*
- YES
- SOMETIMES
- NOT YET
2. Does your child climb onto furniture or other large objects, such as large climbing blocks?*
- 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?*
- YES
- SOMETIMES
- NOT YET
4. Does your child move around by walking, rather than crawling on her hands and knees?*
- YES
- SOMETIMES
- NOT YET
5. Does your child walk well and seldom fall?*
- 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)?*
- YES
- SOMETIMES
- NOT YET

1. Does your child help turn the pages of a book? (You may lift a page for her to grasp.)*
- 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.)*
- 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.)*
- YES
- SOMETIMES
- NOT YET
4. Does your child stack three small blocks or toys on top of each other by herself?*
- 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?*
- 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.)*
- 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.)*
- 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)?*
- 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.)*
- 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?*
- 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)?*
- 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.)*
- YES
- SOMETIMES
- NOT YET

1. Does your child feed himself with a spoon, even though he may spill some food?*
- YES
- SOMETIMES
- NOT YET
2. Does your child help undress herself by taking off clothes like socks, hat, shoes, or mittens?*
- YES
- SOMETIMES
- NOT YET
3. Does your child play with a doll or stuffed animal by hugging it?*
- YES
- SOMETIMES
- NOT YET
4. While looking at himself in the mirror, does your child offer a toy to his own image?*
- YES
- SOMETIMES
- NOT YET
5. Does your child get your attention or try to show you something by pulling on your hand or clothes?*
- 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?*
- YES
- SOMETIMES
- NOT YET

1. Do you think your child hears well?*
- YES
- NO
Please explain:*
2. Do you think your child talks like other toddlers his age?*
- YES
- NO
Please explain:*
3. Can you understand most of what your child says?*
- YES
- NO
Please explain:*
4. Do you think your child walks, runs, and climbs like other toddlers her age?*
- YES
- NO
Please explain:*
5. Does either parent have a family history of childhood deafness or hearing impairment?*
- YES
- NO
Please explain:*
6. Do you have concerns about your child's vision?*
- YES
- NO
Please explain:*
7. Has your child had any medical problems in the last several months?*
- YES
- NO
Please explain:*
8. Do you have any concerns about your child’s behavior?*
- YES
- NO
Please explain:*
9. Does anything about your child worry you?*
- YES
- NO
Please explain:*