ASQ-3 – 06 Month Questionnaire - Pediatric People

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ASQ-3 – 06 Month QuestionnaireMichael2021-02-15T17:34:42-06:00

ASQ-3 - 06 MONTH QUESTIONNAIRE

1PATIENT INFO

2COMMUNICATION

3GROSS MOTOR

4FINE MOTOR

5PROBLEM SOLVING

6PERSONAL - SOCIAL

7OVERALL

PATIENT NAME*
First Last
DATE OF BIRTH*
FORM COMPLETED BY*
First Last

1. Does your baby make high-pitched squeals?*
- YES
- SOMETIMES
- NOT YET
2. When playing with sounds, does your baby make grunting, growling, or other deep-toned sounds?*
- YES
- SOMETIMES
- NOT YET
3. If you call your baby when you are out of sight, does she look in the direction of your voice?*
- YES
- SOMETIMES
- NOT YET
4. When a loud noise occurs, does your baby turn to see where the sound came from?*
- YES
- SOMETIMES
- NOT YET
5. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?*
- YES
- SOMETIMES
- NOT YET
6. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?*
- YES
- SOMETIMES
- NOT YET

1. While your baby is on his back, does your baby lift his legs high enough to see his feet?*
- YES
- SOMETIMES
- NOT YET
2. When your baby is on her tummy, does she straighten both arms and push her whole chest off the bed or floor?*
- YES
- SOMETIMES
- NOT YET
3. Does your baby roll from his back to his tummy, getting both arms out from under him?*
- YES
- SOMETIMES
- NOT YET
4. When you put your baby on the floor, does she lean on her hands while sitting? (If she already sits up straight without leaning on her hands, mark “yes” for this item.)*
- YES
- SOMETIMES
- NOT YET
5. If you hold both hands just to balance your baby, does he support his own weight while standing?*
- YES
- SOMETIMES
- NOT YET
6. Does your baby get into a crawling position by getting up on her hands and knees?*
- YES
- SOMETIMES
- NOT YET

1. Does your baby grab a toy you offer and look at it, wave it about, or chew on it for about 1 minute?*
- YES
- SOMETIMES
- NOT YET
2. Does your baby reach for or grasp a toy using both hands at once?*
- YES
- SOMETIMES
- NOT YET
3. Does your baby reach for a crumb or Cheerio and touch it with his finger or hand? (If he already picks up a small object the size of a pea, mark “yes” for this item.)*
- YES
- SOMETIMES
- NOT YET
4. Does your baby pick up a small toy, holding it in the center of her hand with her fingers around it?*
- YES
- SOMETIMES
- NOT YET
5. Does your baby try to pick up a crumb or Cheerio by using his thumb and all of his fingers in a raking motion, even if he isn’t able to pick it up? (If he already picks up the crumb or Cheerio, mark “yes” for this item.)*
- YES
- SOMETIMES
- NOT YET
6. Does your baby pick up a small toy with only one hand?*
- YES
- SOMETIMES
- NOT YET

1. When a toy is in front of your baby, does she reach for it with both hands?*
- YES
- SOMETIMES
- NOT YET
2. When your baby is on his back, does he turn his head to look for a toy when he drops it? (If he already picks it up, mark “yes” for this item.)*
- YES
- SOMETIMES
- NOT YET
3. When your baby is on her back, does she try to get a toy she has dropped if she can see it?*
- YES
- SOMETIMES
- NOT YET
4. Does your baby pick up a toy and put it in his mouth?*
- YES
- SOMETIMES
- NOT YET
5. Does your baby pass a toy back and forth from one hand to the other?*
- YES
- SOMETIMES
- NOT YET
6. Does your baby play by banging a toy up and down on the floor or table?*
- YES
- SOMETIMES
- NOT YET

1. When in front of a large mirror, does your baby smile or coo at herself?*
- YES
- SOMETIMES
- NOT YET
2. Does your baby act differently toward strangers than he does with you and other familiar people? (Reactions to strangers may include staring, frowning, withdrawing, or crying.)*
- YES
- SOMETIMES
- NOT YET
3. While lying on her back, does your baby play by grabbing her foot?*
- YES
- SOMETIMES
- NOT YET
4. When in front of a large mirror, does your baby reach out to pat the mirror?*
- YES
- SOMETIMES
- NOT YET
5. While your baby is on his back, does he put his foot in his mouth?*
- YES
- SOMETIMES
- NOT YET
6. Does your baby try to get a toy that is out of reach? (She may roll, pivot on her tummy, or crawl to get it.)*
- 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:*