ASQ-3 – 04 Month Questionnaire - Pediatric People

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ASQ-3 – 04 Month QuestionnaireMichael2021-02-15T17:33:59-06:00

ASQ-3 - 04 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 baby chuckle softly?*
- YES
- SOMETIMES
- NOT YET
2. After you have been out of sight, does your baby smile or get excited when he sees you?*
- YES
- SOMETIMES
- NOT YET
3. Does your baby stop crying when she hears a voice other than yours?*
- YES
- SOMETIMES
- NOT YET
4. Does your baby make high-pitched squeals?*
- YES
- SOMETIMES
- NOT YET
5. Does your baby laugh?*
- YES
- SOMETIMES
- NOT YET
6. Does your baby make sounds when looking at toys or people?*
- YES
- SOMETIMES
- NOT YET

1. While your baby is on his back, does he move his head from side to side?*
- YES
- SOMETIMES
- NOT YET
2. 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
3. When your baby is on his tummy, does he hold his head up so that his chin is about 3 inches from the floor for at least 15 seconds?*
- YES
- SOMETIMES
- NOT YET
4. When your baby is on her tummy, does she hold her head straight up, looking around? (She can rest on her arms while doing this.)*
- YES
- SOMETIMES
- NOT YET
5. When you hold him in a sitting position, does your baby hold his head steady?*
- YES
- SOMETIMES
- NOT YET
6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?*
- YES
- SOMETIMES
- NOT YET

1. Does your baby hold his hands open or partly open (rather than in fists, as they were when he was a newborn)?*
- YES
- SOMETIMES
- NOT YET
2. When you put a toy in her hand, does your baby wave it about, at least briefly?*
- YES
- SOMETIMES
- NOT YET
3. Does your baby grab or scratch at his clothes?*
- YES
- SOMETIMES
- NOT YET
4. When you put a toy in her hand, does your baby hold onto it for about 1 minute while looking at it, waving it about, or trying to chew it?*
- YES
- SOMETIMES
- NOT YET
5. Does your baby grab or scratch his fingers on a surface in front of him, either while being held in a sitting position or when he is on his tummy?*
- YES
- SOMETIMES
- NOT YET
6. When you hold your baby in a sitting position, does she reach for a toy on a table close by, even though her hand may not touch it?*
- YES
- SOMETIMES
- NOT YET

1. 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 his eyes, sometimes turning his head?*
- YES
- SOMETIMES
- NOT YET
2. 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 her eyes?*
- YES
- SOMETIMES
- NOT YET
3. When you hold your baby in a sitting position, does he look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of him?*
- YES
- SOMETIMES
- NOT YET
4. When you put a toy in her hand, does your baby look at it?*
- YES
- SOMETIMES
- NOT YET
5. When you put a toy in his hand, does your baby put the toy in his mouth?*
- YES
- SOMETIMES
- NOT YET
6. When you dangle a toy above your baby while she is lying on her back, does your baby wave her arms toward the toy?*
- YES
- SOMETIMES
- NOT YET

1. Does your baby watch his hands?*
- YES
- SOMETIMES
- NOT YET
2. When your baby has her hands together, does she play with her fingers?*
- YES
- SOMETIMES
- NOT YET
3. When your baby sees the breast or bottle, does he seem to know he is about to be fed?*
- YES
- SOMETIMES
- NOT YET
4. Does your baby help hold the bottle with both hands at once, or when nursing, does she hold the breast with her free hand?*
- YES
- SOMETIMES
- NOT YET
5. Before you smile or talk to your baby, does he smile when he sees you nearby?*
- YES
- SOMETIMES
- NOT YET
6. When in front of a large mirror, does your baby smile or coo at herself?*
- YES
- SOMETIMES
- NOT YET

1. Does your baby use both hands and both legs equally well?*
- YES
- NO
Please explain:*
2. When you help your baby stand, are his feet flat on the surface most of the time?*
- YES
- NO
Please explain:*
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*
- YES
- NO
Please explain:*
4. Does either parent have a family history of childhood deafness or hearing impairment?*
- YES
- NO
Please explain:*
5. Do you have concerns about your baby’s vision*
- YES
- NO
Please explain:*
6. Has your baby had any medical problems in the last several months?*
- YES
- NO
Please explain:*
7. Do you have any concerns about your baby’s behavior?*
- YES
- NO
Please explain:*
8. Does anything about your baby worry you?*
- YES
- NO
Please explain:*