ASQ-3 - 02 Month Questionnaire - Pediatric People

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ASQ-3 – 02 Month QuestionnaireMichael2025-08-07T15:39:33-05:00

2 MONTH ASSESSMENT

"*" indicates required fields

PATIENT NAME*

First Last

DATE OF BIRTH*

Month

Day

Year

FORM COMPLETED BY*

First Last

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DOS

1. Does your baby sometimes make throaty or gurgling sounds?*

YES

SOMETIMES

NOT YET

2. Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?*

YES

SOMETIMES

NOT YET

3. When you speak to your baby, does she make sounds back to you?*

YES

SOMETIMES

NOT YET

4. Does your baby smile when you talk to him?*

YES

SOMETIMES

NOT YET

5. Does your baby chuckle softly?*

YES

SOMETIMES

NOT YET

6. After you have been out of sight, does your baby smile or get excited when she sees you?*

YES

SOMETIMES

NOT YET

1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?*

YES

SOMETIMES

NOT YET

2. When your baby is on her tummy, does she turn her head to the side?*

YES

SOMETIMES

NOT YET

3. When your baby is on his tummy, does he hold his head up longer than a few seconds?*

YES

SOMETIMES

NOT YET

4. When your baby is on her back, does she kick her legs?*

YES

SOMETIMES

NOT YET

5. While your baby is on his back, does he move his head from side to side?*

YES

SOMETIMES

NOT YET

6. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?*

YES

SOMETIMES

NOT YET

1. Is your baby’s hand usually tightly closed when he is awake? (If your baby used to do this but no longer does, mark “yes.”)*

YES

SOMETIMES

NOT YET

2. Does your baby grasp your finger if you touch the palm of her hand?*

YES

SOMETIMES

NOT YET

3. When you put a toy in his hand, does your baby hold it in his hand briefly?*

YES

SOMETIMES

NOT YET

4. Does your baby touch her face with her hands?*

YES

SOMETIMES

NOT YET

5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?*

YES

SOMETIMES

NOT YET

6. Does your baby grab or scratch at her clothes?*

YES

SOMETIMES

NOT YET

1. Does your baby look at objects that are 8–10 inches away?*

YES

SOMETIMES

NOT YET

2. When you move around, does your baby follow you with his eyes?*

YES

SOMETIMES

NOT YET

3. When you move a toy slowly from side to side in front of your baby’s face (about 10 inches away), does your baby follow the toy with her eyes, sometimes turning her head?*

YES

SOMETIMES

NOT YET

4. When you move a small toy up and down slowly in front of your baby’s face (about 10 inches away), does your baby follow the toy with his eyes?*

YES

SOMETIMES

NOT YET

5. When you hold your baby in a sitting position, does she look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?*

YES

SOMETIMES

NOT YET

6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?*

YES

SOMETIMES

NOT YET

1. Does your baby sometimes try to suck, even when she’s not feeding?*

YES

SOMETIMES

NOT YET

2. Does your baby cry when he is hungry, wet, tired, or wants to be held?*

YES

SOMETIMES

NOT YET

3. Does your baby smile at you?*

YES

SOMETIMES

NOT YET

4. When you smile at your baby, does she smile back?*

YES

SOMETIMES

NOT YET

5. Does your baby watch his hands?*

YES

SOMETIMES

NOT YET

6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?*

YES

SOMETIMES

NOT YET

1. Did your baby pass the newborn hearing screening test?*

YES

NO

Please explain:*

2. Does your baby move both hands and both legs equally well?*

YES

NO

Please explain:*

3. Does either parent have a family history of childhood deafness, hearing impairment, or vision problems?*

YES

NO

Please explain:*

4. Has your baby had any medical problems?*

YES

NO

Please explain:*

5. Do you have concerns about your baby’s behavior (for example, eating, sleeping)?*

YES

NO

Please explain:*

6. Does anything about your baby worry you?*

YES

NO

Please explain:*