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ASQ-3 – 60 Month Questionnaire
Michael
2021-02-15T17:32:14-06:00
ASQ-3 - 60 MONTH QUESTIONNAIRE
1
PATIENT INFO
2
COMMUNICATION
3
GROSS MOTOR
4
FINE MOTOR
5
PROBLEM SOLVING
6
PERSONAL - SOCIAL
7
OVERALL
PATIENT NAME
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First
Last
DATE OF BIRTH
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Month
1
2
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Day
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Year
2022
2021
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FORM COMPLETED BY
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First
Last
1. Without your giving help by pointing or repeating directions, 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
2. Does your child use four- and five-word sentences? For example, does your child say, “I want the car”?
*
YES
SOMETIMES
NOT YET
Please give an example:
*
3. When talking about something that already happened, does your child use words that end in “-ed,” such as “walked,” “jumped,” or “played”? Ask your child questions, such as “How did you get to the store?” (“We walked.”) “What did you do at your friend’s house?” (“We played.”)
*
YES
SOMETIMES
NOT YET
Please give an example:
*
4. Does your child use comparison words, such as “heavier,” “stronger,” or “shorter”? Ask your child questions, such as “A car is big, but a bus is _____” (bigger); “A cat is heavy, but a man is _____” (heavier); “A TV is small, but a book is _____” (smaller).
*
YES
SOMETIMES
NOT YET
Please give an example:
*
5. 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?”
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Your child's response to question, “What do you do when you are tired?”
*
6. Does your child repeat the sentences shown below back to you, without any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark “yes” if your child repeats both sentences without mistakes or “sometimes” if your child repeats one sentence without mistakes.)
*
YES
SOMETIMES
NOT YET
1. 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.”)
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YES
SOMETIMES
NOT YET
2. 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.)
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YES
SOMETIMES
NOT YET
3. 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.)
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YES
SOMETIMES
NOT YET
4. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)
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YES
SOMETIMES
NOT YET
5. Does your child hop forward on one foot for a distance of 4–6 feet without putting down the other foot? (You may give her two tries on each foot. Mark “sometimes” if she can hop on one foot only.)
*
YES
SOMETIMES
NOT YET
6. Does your child skip using alternating feet? (You may show him how to do this.)
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YES
SOMETIMES
NOT YET
1.Draw a line, like the one below, and ask your child to trace on the line with a pencil. Does your child trace on the line without going off the line more than two times? (Mark “sometimes” if your child goes off the line three times.)
*
YES
SOMETIMES
NOT YET
2. Ask your child to draw a picture of a person below. You may ask your child, “Draw a picture of a girl or a boy.” If your child draws a person with head, body, arms, and legs, mark “yes.” If your child draws a person with only three parts (head, body, arms, or legs), mark “sometimes.” If your child draws a person with two or fewer parts (head, body, arms, or legs), mark “not yet.”
*
YES
SOMETIMES
NOT YET
(Optional: Space for child to draw a person)
3. Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.)
*
YES
SOMETIMES
NOT YET
4. Using the shapes below to look at, does your child copy the shapes in the space below without tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size. Mark “yes” if she copies all three shapes; mark “sometimes” if your child copies two shapes.)
*
YES
SOMETIMES
NOT YET
(Optional: Space for child to draw shapes)
5. Using the letters below to look at, does your child copy the letters without tracing? Cover up all of the letters except the letter being copied. (Mark “yes” if your child copies four of the letters and you can read them. Mark “sometimes” if your child copies two or three letters and you can read them.)
*
YES
SOMETIMES
NOT YET
(Optional: Space for child to write letters)
6. Print your child’s first name. Can your child copy the letters? The letters may be large, backward, or reversed. (Mark “sometimes” if your child copies about half of the letters.)
*
YES
SOMETIMES
NOT YET
(Optional: Space for adult's printing)
(Optional: Space for child's printing)
1. When asked, “Which circle is 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
2. 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
3. Does your child count up to 15 without making mistakes? If so, mark “yes.” If your child counts to 12 without making mistakes, mark “sometimes.”
*
YES
SOMETIMES
NOT YET
4. Does your child finish the following sentences using a word that means the opposite of the word that is written in all capital letters? For example: “A rock is HARD, and a pillow is SOFT.” (Mark “yes” if he finishes three of four sentences correctly. (Mark “sometimes” if he finishes two of four sentences correctly.)
*
YES
SOMETIMES
NOT YET
A cow is BIG, and a mouse is...
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Ice is COLD, and fire is...
*
We see stars at NIGHT, and we see the sun during the...
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When I throw the ball UP, it comes...
*
5. Does your child know the names of numbers? (Mark “yes” if she identifies the three numbers below. Mark “sometimes” if she identifies two numbers.)
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YES
SOMETIMES
NOT YET
6. Does your child name at least four letters in her name? Point to the letters and ask, “What letter is this?” (Point to the letters out of order.)
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YES
SOMETIMES
NOT YET
1. Can your child serve himself, 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?
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YES
SOMETIMES
NOT YET
2. Does your child wash her hands and face using soap and water and dry off with a towel without help?
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YES
SOMETIMES
NOT YET
3. Does your child tell you at least four of the following (first name, age, city he lives in, last name, boy or girl, telephone number)?
*
YES
SOMETIMES
NOT YET
Please mark the items your child knows:
*
First name
Age
City he lives in
Last name
Boy or girl
Telephone number
4. Does your child dress and undress himself, including buttoning medium-size buttons and zipping front zippers?
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YES
SOMETIMES
NOT YET
5. Does your child use the toilet by herself? (She goes to the bathroom, sits on the toilet, wipes, and flushes.) Mark “yes” even if she does this after you remind her.
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YES
SOMETIMES
NOT YET
6. Does your child usually take turns and share with other children?
*
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?
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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?
*
YES
NO
Please explain:
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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?
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YES
NO
Please explain:
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