ASQ-3 - 24 Month Questionnaire - Pediatric People

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ASQ-3 – 24 Month QuestionnaireMichael2021-02-15T17:30:13-06:00

ASQ-3 - 24 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. 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:*