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ASQ-3 – 02 Month QuestionnaireMichael2023-05-19T11:31:52-05:00

ASQ-3 - 02 MONTH QUESTIONNAIRE

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PATIENT NAME*
DATE OF BIRTH*
FORM COMPLETED BY*
1. Does your baby sometimes make throaty or gurgling sounds?*
2. Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?*
3. When you speak to your baby, does she make sounds back to you?*
4. Does your baby smile when you talk to him?*
5. Does your baby chuckle softly?*
6. After you have been out of sight, does your baby smile or get excited when she sees you?*
1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?*
2. When your baby is on her tummy, does she turn her head to the side?*
3. When your baby is on his tummy, does he hold his head up longer than a few seconds?*
4. When your baby is on her back, does she kick her legs?*
5. While your baby is on his back, does he move his head from side to side?*
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?*
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.”)*
2. Does your baby grasp your finger if you touch the palm of her hand?*
3. When you put a toy in his hand, does your baby hold it in his hand briefly?*
4. Does your baby touch her face with her hands?*
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)?*
6. Does your baby grab or scratch at her clothes?*
1. Does your baby look at objects that are 8–10 inches away?*
2. When you move around, does your baby follow you with his eyes?*
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?*
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?*
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?*
6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?*
1. Does your baby sometimes try to suck, even when she’s not feeding?*
2. Does your baby cry when he is hungry, wet, tired, or wants to be held?*
3. Does your baby smile at you?*
4. When you smile at your baby, does she smile back?*
5. Does your baby watch his hands?*
6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?*
1. Did your baby pass the newborn hearing screening test?*
2. Does your baby move both hands and both legs equally well?*
3. Does either parent have a family history of childhood deafness, hearing impairment, or vision problems?*
4. Has your baby had any medical problems?*
5. Do you have concerns about your baby’s behavior (for example, eating, sleeping)?*
6. Does anything about your baby worry you?*
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