ASQ-3 - 48 Month Questionnaire - Pediatric People

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ASQ-3 – 48 Month QuestionnaireMichael2021-02-15T17:31:42-06:00

ASQ-3 - 48 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. Does your child name at least three items from a common category? For example, if you say to your child, “Tell me some things that you can eat,” does your child answer with something like “cookies, eggs, and cereal”? Or if you say, “Tell me the names of some animals,” does your child answer with something like “cow, dog, and elephant”?*
- YES
- SOMETIMES
- NOT YET
2. Does your child answer the following questions? (Mark “sometimes” if your child answers only one question.) “What do you do when you are hungry?” (Acceptable answers include “get food,” “eat,” “ask for something to eat,” and “have a snack.”). “What do you do when you are tired?” (Acceptable answers include “take a nap,” “rest,” “go to sleep,” “go to bed,” “lie down,” and “sit down.”).*
- YES
- SOMETIMES
- NOT YET
Your child's response to question, "What do you do when you are hungry?”*
Your child's response to question, “What do you do when you are tired?”*
3. Does your child tell you at least two things about common objects? For example, if you say to your child, “Tell me about your ball,” does she say something like, “It’s round. I throw it. It’s big”?*
- YES
- SOMETIMES
- NOT YET
4. Does your child use endings of words, such as “-s,” “-ed,” and “-ing”? For example, does your child say things like, “I see two cats,” “I am playing,” or “I kicked the ball”?*
- YES
- SOMETIMES
- NOT YET
5. Without your giving help by pointing or repeating, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, “Clap your hands, walk to the door, and sit down,” or “Give me the pen, open the book, and stand up.”*
- YES
- SOMETIMES
- NOT YET
6. Does your child use all of the words in a sentence (for example, “a,” “the,” “am,” “is,” and “are”) to make complete sentences, such as “I am going to the park,” or “Is there a toy to play with?” or “Are you coming, too?”*
- YES
- SOMETIMES
- NOT YET

1. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)*
- YES
- SOMETIMES
- NOT YET
2. Does your child climb the rungs of a ladder of a playground slide and slide down without help?*
- YES
- SOMETIMES
- NOT YET
3. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)*
- YES
- SOMETIMES
- NOT YET
4. Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?*
- YES
- SOMETIMES
- NOT YET
5. Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together?*
- YES
- SOMETIMES
- NOT YET
6. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)*
- YES
- SOMETIMES
- NOT YET

1. Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)*
- YES
- SOMETIMES
- NOT YET
2. Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down? (Carefully wa*
- YES
- SOMETIMES
- NOT YET
3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, without tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.)*
- YES
- SOMETIMES
- NOT YET
4. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll’s clothing.)*
- YES
- SOMETIMES
- NOT YET
5. Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?*
- YES
- SOMETIMES
- NOT YET
6. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.)*
- YES
- SOMETIMES
- NOT YET

1. 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 to answer “yes” to this question.)*
- YES
- SOMETIMES
- NOT YET
2. When asked, “Which circle is the smallest?” does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)*
- YES
- SOMETIMES
- NOT YET
3. Without your giving help by pointing, does your child follow three different directions using the words “under,” “between,” and “middle”? For example, ask your child to put the shoe “under the couch.” Then ask her to put the ball “between the chairs” and the book “in the middle of the table.”*
- YES
- SOMETIMES
- NOT YET
Please write your child’s response here:*
4. When shown objects and asked, “What color is this?” does your child name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark “yes” only if your child answers the question correctly using five colors.)*
- YES
- SOMETIMES
- NOT YET
5. Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.*
- YES
- SOMETIMES
- NOT YET
6. If you place five objects in front of your child, can he count them by saying, “one, two, three, four, five,” in order? (Ask this question without providing help by pointing, gesturing, or naming.)*
- YES
- SOMETIMES
- NOT YET

1. Does your child serve herself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?*
- YES
- SOMETIMES
- NOT YET
2. Does your child tell you at least four of the following (first name, age, city she lives in, last name, boy or girl, telephone number)?*
- YES
- SOMETIMES
- NOT YET
Please mark the items your child knows:*
- First name
- Age
- City she lives in
- Last name
- Boy or girl
- Telephone number
3. Does your child wash his hands using soap and water and dry off with a towel without help?*
- YES
- SOMETIMES
- NOT YET
4. Does your child tell you the names of two or more playmates, not including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)*
- YES
- SOMETIMES
- NOT YET
5. Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all of her teeth without help? (You may still need to check and rebrush your child’s teeth.)*
- YES
- SOMETIMES
- NOT YET
6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?*
- 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:*