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ASQ-3 – 18 Month Questionnaire
Michael
2025-09-23T11:29:04-05:00
18 MONTH ASSESSMENT
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" indicates required fields
PATIENT NAME
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First
Last
DATE OF BIRTH
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Month
Month
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Day
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Year
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MRN
1. When your child wants something, does she tell you by pointing to it?
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YES
SOMETIMES
NOT YET
2. 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
3. Does your child say eight or more words in addition to “Mama” and “Dada”?
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YES
SOMETIMES
NOT YET
4. 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
5. Without your showing him, does your child point to the correct picture when you say, “Show me the kitty,” or ask, “Where is the dog?” (He needs to identify only one picture correctly.)
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YES
SOMETIMES
NOT YET
6. Does your child say two or three words that represent different ideas together, such as “See dog,” “Mommy come home,” or “Kitty gone”? (Don’t count word combinations that express one idea, such as “byebye,” “all gone,” “all right,” and “What’s that?”)
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YES
SOMETIMES
NOT YET
Please give an example of your child’s word combinations:
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1. 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
2. Does your child move around by walking, rather than by crawling on her hands and knees?
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YES
SOMETIMES
NOT YET
3. Does your child walk well and seldom fall?
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YES
SOMETIMES
NOT YET
4. 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
5. Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
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YES
SOMETIMES
NOT YET
6. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (If your child already kicks a ball, mark “yes” for this item.)
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YES
SOMETIMES
NOT YET
1. 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
2. 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
3. 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
4. Does your child stack three small blocks or toys on top of each other by himself?
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YES
SOMETIMES
NOT YET
5. 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
6. Does your child get a spoon into her mouth right side up so that the food usually doesn’t spill?
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YES
SOMETIMES
NOT YET
1. 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
2. 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
3. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle over to dump it out? (You may show him how.) (You can use a soda-pop bottle or a baby bottle.)
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YES
SOMETIMES
NOT YET
4. Without your showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)?
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YES
SOMETIMES
NOT YET
5. After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark “not yet” if your child scribbles back and forth.)
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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 out the crumb or Cheerio? (Do not show him how.)
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YES
SOMETIMES
NOT YET
1. While looking at herself in the mirror, does your child offer a toy to her own image?
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YES
SOMETIMES
NOT YET
2. Does your child play with a doll or stuffed animal by hugging it?
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YES
SOMETIMES
NOT YET
3. 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
4. Does your child come to you when he needs help, such as with winding up a toy or unscrewing a lid from a jar?
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YES
SOMETIMES
NOT YET
5. Does your child drink from a cup or glass, putting it down again with little spilling?
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YES
SOMETIMES
NOT YET
6. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?
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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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