ASQ-3 - 02 Month Questionnaire - Pediatric People

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ASQ-3 – 02 Month QuestionnaireMichael2021-02-25T08:23:00-06:00

ASQ-3 - 02 MONTH QUESTIONNAIRE

1PATIENT INFO

2COMMUNICATION

3GROSS MOTOR

4FINE MOTOR

5PROBLEM SOLVING

6PERSONAL - SOCIAL

7OVERALL

PATIENT NAME*
First Last
DATE OF BIRTH*
FORM COMPLETED BY*
First Last

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:*