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ASQ-3 – 36 Month Questionnaire
Michael
2025-09-23T11:29:46-05:00
36 MONTH ASSESSMENT
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" indicates required fields
PATIENT NAME
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First
Last
DATE OF BIRTH
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Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
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31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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2005
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2001
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1931
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1920
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MRN
1. When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark “sometimes” if she correctly points to at least three different body parts.)
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YES
SOMETIMES
NOT YET
2. Does your child make sentences that are three or four words long?
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YES
SOMETIMES
NOT YET
Please give an example:
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3. Without giving your child help by pointing or using gestures, ask him to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly?
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YES
SOMETIMES
NOT YET
4. When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, “barking,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?”
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YES
SOMETIMES
NOT YET
5. Show your child how a zipper on a coat moves up and down, and say, “See, this goes up and down.” Put the zipper to the middle and ask your child to move the zipper down. Return the zipper to the middle and ask your child to move the zipper up. Do this several times, placing the zipper in the middle before asking your child to move it up or down. Does your child consistently move the zipper up when you say “up” and down when you say “down”?
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YES
SOMETIMES
NOT YET
6. When you ask, “What is your name?” does your child say both her first and last names?
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YES
SOMETIMES
NOT YET
1. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
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YES
SOMETIMES
NOT YET
2. Does your child jump with both feet leaving the floor at the same time?
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YES
SOMETIMES
NOT YET
3. Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
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YES
SOMETIMES
NOT YET
4. Does your child stand on one foot for about 1 second without holding onto anything?
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YES
SOMETIMES
NOT YET
5. While standing, does your child throw a ball overhand by raising his arm to shoulder height and throwing the ball forward? (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)
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YES
SOMETIMES
NOT YET
6. Does your child jump forward at least 6 inches with both feet leaving the ground at the same time?
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YES
SOMETIMES
NOT YET
1. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction?
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YES
SOMETIMES
NOT YET
2. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
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YES
SOMETIMES
NOT YET
3. After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?
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YES
SOMETIMES
NOT YET
4. After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction?
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YES
SOMETIMES
NOT YET
5. Does your child try to cut paper with child-safe scissors? He does not need to cut the paper but must get the blades to open and close while holding the paper with the other hand. (You may show your child how to use scissors. Carefully watch your child’s use of scissors for safety reasons.)
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YES
SOMETIMES
NOT YET
6. When drawing, does your child hold a pencil, crayon, or pen between her fingers and thumb like an adult does?
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YES
SOMETIMES
NOT YET
1. 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.)
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YES
SOMETIMES
NOT YET
2. If your child wants something he cannot reach, does he 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)?
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YES
SOMETIMES
NOT YET
3. When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”)
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YES
SOMETIMES
NOT YET
Please write your child’s response here:
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4. When you say, “Say ‘seven three,’” does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, “Say ‘eight two.’” (Your child must repeat just one series of two numbers for you to answer “yes” to this question.)
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YES
SOMETIMES
NOT YET
5. Show your child how to make a bridge with blocks, boxes, or cans, like the example. Does your child copy you by making one like it?
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YES
SOMETIMES
NOT YET
6. When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers for you to answer “yes” to this question.)
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YES
SOMETIMES
NOT YET
1. Does your child use a spoon to feed herself with little spilling?
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YES
SOMETIMES
NOT YET
2. Does your child push a little wagon, stroller, or toy on wheels, steering it around objects and backing out of corners if he cannot turn?
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YES
SOMETIMES
NOT YET
3. When your child is looking in a mirror and you ask, “Who is in the mirror?” does she say either “me” or her own name?
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YES
SOMETIMES
NOT YET
4. Does your child put on a coat, jacket, or shirt by himself?
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YES
SOMETIMES
NOT YET
5. Using these exact words, ask your child, “Are you a girl or a boy?” Does your child answer correctly?
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YES
SOMETIMES
NOT YET
6. Does your child take turns by waiting while another child or adult takes a turn?
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YES
SOMETIMES
NOT YET
1. Do you think your child hears well?
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YES
NO
Please explain:
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2. Do you think your child talks like other children his age?
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YES
NO
Please explain:
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3. Can you understand most of what your child says?
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YES
NO
Please explain:
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4. Can other people understand most of what your child says?
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YES
NO
Please explain:
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5. Do you think your child walks, runs, and climbs like other toddlers her age?
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YES
NO
Please explain:
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6. Does either parent have a family history of childhood deafness or hearing impairment?
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YES
NO
Please explain:
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7. Do you have concerns about your child's vision?
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YES
NO
Please explain:
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8. Has your child had any medical problems in the last several months?
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YES
NO
Please explain:
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9. Do you have any concerns about your child’s behavior?
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YES
NO
Please explain:
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10. Does anything about your child worry you?
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YES
NO
Please explain:
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