ASQ-3 - 36 Month Questionnaire - Pediatric People

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ASQ-3 – 36 Month QuestionnaireMichael2021-02-15T17:30:59-06:00

ASQ-3 - 36 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. 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.)*
- YES
- SOMETIMES
- NOT YET
2. Does your child make sentences that are three or four words long?*
- YES
- SOMETIMES
- NOT YET
Please give an example:*
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?*
- 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?”*
- 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”?*
- YES
- SOMETIMES
- NOT YET
6. When you ask, “What is your name?” does your child say both her first and last names?*
- YES
- SOMETIMES
- NOT YET

1. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?*
- YES
- SOMETIMES
- NOT YET
2. Does your child jump with both feet leaving the floor at the same time?*
- 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.)*
- YES
- SOMETIMES
- NOT YET
4. Does your child stand on one foot for about 1 second without holding onto anything?*
- 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.”)*
- YES
- SOMETIMES
- NOT YET
6. Does your child jump forward at least 6 inches with both feet leaving the ground at the same time?*
- 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?*
- YES
- SOMETIMES
- NOT YET
2. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?*
- 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?*
- 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?*
- 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.)*
- 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?*
- 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.)*
- 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)?*
- 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.”)*
- YES
- SOMETIMES
- NOT YET
Please write your child’s response here:*
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.)*
- 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?*
- 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.)*
- YES
- SOMETIMES
- NOT YET

1. Does your child use a spoon to feed herself with little spilling?*
- 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?*
- 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?*
- YES
- SOMETIMES
- NOT YET
4. Does your child put on a coat, jacket, or shirt by himself?*
- YES
- SOMETIMES
- NOT YET
5. Using these exact words, ask your child, “Are you a girl or a boy?” Does your child answer correctly?*
- YES
- SOMETIMES
- NOT YET
6. Does your child take turns by waiting while another child or adult takes a turn?*
- 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 children his age?*
- YES
- NO
Please explain:*
3. Can you understand most of what your child says?*
- YES
- NO
Please explain:*
4. Can other people understand most of what your child says?*
- YES
- NO
Please explain:*
5. Do you think your child walks, runs, and climbs like other toddlers her age?*
- YES
- NO
Please explain:*
6. Does either parent have a family history of childhood deafness or hearing impairment?*
- YES
- NO
Please explain:*
7. Do you have concerns about your child's vision?*
- YES
- NO
Please explain:*
8. Has your child had any medical problems in the last several months?*
- YES
- NO
Please explain:*
9. Do you have any concerns about your child’s behavior?*
- YES
- NO
Please explain:*
10. Does anything about your child worry you?*
- YES
- NO
Please explain:*