Skip to content
ASQ-3 – 24 Month Questionnaire
Michael
2025-09-23T11:29:22-05:00
24 MONTH ASSESSMENT
"
*
" indicates required fields
PATIENT NAME
*
First
Last
DATE OF BIRTH
*
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
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
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
This field is hidden when viewing the form
MRN
1. 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?” (She needs to identify only one picture correctly.)
*
YES
SOMETIMES
NOT YET
2. 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
3. Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions (“Put the toy on the table.” “Find your coat." “Close the door.” “Take my hand.” “Bring me a towel.” “Get your book.”)?
*
YES
SOMETIMES
NOT YET
Which of these directions can your child carry out?
*
“Put the toy on the table.”
“Find your coat."
“Close the door.”
“Take my hand.”
“Bring me a towel.”
“Get your book.”)
4. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, “What is this?” does your child correctly name at least one picture?
*
YES
SOMETIMES
NOT YET
5. 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?”)
*
YES
SOMETIMES
NOT YET
Please give an example of your child’s word combinations:
*
6. Does your child correctly use at least two words like “me,” “I,” “mine,” and “you”?
*
YES
SOMETIMES
NOT YET
1. 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.)
*
YES
SOMETIMES
NOT YET
2. 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.)
*
YES
SOMETIMES
NOT YET
3. Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wall.
*
YES
SOMETIMES
NOT YET
4. Does your child run fairly well, stopping herself without bumping into things or falling?
*
YES
SOMETIMES
NOT YET
5. Does your child jump with both feet leaving the floor at the same time?
*
YES
SOMETIMES
NOT YET
6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
*
YES
SOMETIMES
NOT YET
1. Does your child get a spoon into his mouth right side up so that the food usually doesn’t spill?
*
YES
SOMETIMES
NOT YET
2. Does your child turn the pages of a book by herself? (She may turn more than one page at a time.)
*
YES
SOMETIMES
NOT YET
3. Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?
*
YES
SOMETIMES
NOT YET
4. Does your child flip switches off and on?
*
YES
SOMETIMES
NOT YET
5. Does your child stack seven small blocks or toys on top of each other by herself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)
*
YES
SOMETIMES
NOT YET
6. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
*
YES
SOMETIMES
NOT YET
1. 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.)
*
YES
SOMETIMES
NOT YET
2. 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.) (You can use a soda-pop bottle or baby bottle.)
*
YES
SOMETIMES
NOT YET
3. Does your child pretend objects are something else? For example, does your child hold a cup to her ear, pretending it is a telephone? Does she put a box on her head, pretending it is a hat? Does she use a block or small toy to stir food?
*
YES
SOMETIMES
NOT YET
4. Does your child put things away where they belong? For example, does he know his toys belong on the toy shelf, his blanket goes on his bed, and dishes go in the kitchen?
*
YES
SOMETIMES
NOT YET
5. If your child wants something she cannot reach, does she find a chair or box to stand on to reach it (for example, to get a toy on a counter or to “help” you in the kitchen)?
*
YES
SOMETIMES
NOT YET
6. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.)
*
YES
SOMETIMES
NOT YET
1. Does your child drink from a cup or glass, putting it down again with little spilling?
*
YES
SOMETIMES
NOT YET
2. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?
*
YES
SOMETIMES
NOT YET
3. Does your child eat with a fork?
*
YES
SOMETIMES
NOT YET
4. When playing with either a stuffed animal or a doll, does your child pretend to rock it, feed it, change its diapers, put it to bed, and so forth?
*
YES
SOMETIMES
NOT YET
5. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if he cannot turn?
*
YES
SOMETIMES
NOT YET
6. Does your child call herself “I” or “me” more often than her own name? For example, “I do it,” more often than “Juanita do it.”
*
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:
*
Page load link
