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

ASQ-3 - 04 MONTH QUESTIONNAIRE

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PATIENT NAME*
DATE OF BIRTH*
FORM COMPLETED BY*
1. Does your baby chuckle softly?*
2. After you have been out of sight, does your baby smile or get excited when he sees you?*
3. Does your baby stop crying when she hears a voice other than yours?*
4. Does your baby make high-pitched squeals?*
5. Does your baby laugh?*
6. Does your baby make sounds when looking at toys or people?*
1. While your baby is on his back, does he move his head from side to side?*
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?*
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?*
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.)*
5. When you hold him in a sitting position, does your baby hold his head steady?*
6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?*
1. Does your baby hold his hands open or partly open (rather than in fists, as they were when he was a newborn)?*
2. When you put a toy in her hand, does your baby wave it about, at least briefly?*
3. Does your baby grab or scratch at his clothes?*
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?*
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?*
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?*
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?*
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?*
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?*
4. When you put a toy in her hand, does your baby look at it?*
5. When you put a toy in his hand, does your baby put the toy in his mouth?*
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?*
1. Does your baby watch his hands?*
2. When your baby has her hands together, does she play with her fingers?*
3. When your baby sees the breast or bottle, does he seem to know he is about to be fed?*
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?*
5. Before you smile or talk to your baby, does he smile when he sees you nearby?*
6. When in front of a large mirror, does your baby smile or coo at herself?*
1. Does your baby use both hands and both legs equally well?*
2. When you help your baby stand, are his feet flat on the surface most of the time?*
3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*
4. Does either parent have a family history of childhood deafness or hearing impairment?*
5. Do you have concerns about your baby’s vision*
6. Has your baby had any medical problems in the last several months?*
7. Do you have any concerns about your baby’s behavior?*
8. Does anything about your baby worry you?*
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