ASQ-3 – 09 Month Questionnaire - Pediatric People

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ASQ-3 – 09 Month QuestionnaireMichael2021-02-15T17:35:54-06:00

ASQ-3 - 09 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 sounds like “da,” “ga,” “ka,” and “ba”?*
- YES
- SOMETIMES
- NOT YET
2. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?*
- YES
- SOMETIMES
- NOT YET
3. Does your baby make two similar sounds like “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)*
- YES
- SOMETIMES
- NOT YET
4. If you ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)?*
- YES
- SOMETIMES
- NOT YET
5. Does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back,” without your using gestures?*
- YES
- SOMETIMES
- NOT YET
6. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)*
- YES
- SOMETIMES
- NOT YET

1. If you hold both hands just to balance your baby, does she support her own weight while standing?*
- YES
- SOMETIMES
- NOT YET
2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?*
- YES
- SOMETIMES
- NOT YET
3. When you stand your baby next to furniture or the crib rail, does she hold on without leaning her chest against the furniture for support?*
- YES
- SOMETIMES
- NOT YET
4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?*
- YES
- SOMETIMES
- NOT YET
5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?*
- YES
- SOMETIMES
- NOT YET
6. Does your baby walk beside furniture while holding on with only one hand?*
- YES
- SOMETIMES
- NOT YET

1. Does your baby pick up a small toy with only one hand?*
- YES
- SOMETIMES
- NOT YET
2. Does your baby successfully pick up a crumb or Cheerio by using her thumb and all of her fingers in a raking motion? (If she already picks up a crumb or Cheerio, mark “yes” for this item.)*
- YES
- SOMETIMES
- NOT YET
3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)*
- YES
- SOMETIMES
- NOT YET
4. After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (The string may be attached to a toy.)*
- YES
- SOMETIMES
- NOT YET
5. Does your baby pick up a crumb or Cheerio with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it.*
- YES
- SOMETIMES
- NOT YET
6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?*
- YES
- SOMETIMES
- NOT YET

1. Does your baby pass a toy back and forth from one hand to the other?*
- YES
- SOMETIMES
- NOT YET
2. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?*
- YES
- SOMETIMES
- NOT YET
3. When holding a toy in his hand, does your baby bang it against another toy on the table?*
- YES
- SOMETIMES
- NOT YET
4. While holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?*
- YES
- SOMETIMES
- NOT YET
5. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?*
- YES
- SOMETIMES
- NOT YET
6. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.)*
- YES
- SOMETIMES
- NOT YET

1. While your baby is on her back, does she put her foot in her mouth?*
- YES
- SOMETIMES
- NOT YET
2. Does your baby drink water, juice, or formula from a cup while you hold it?*
- YES
- SOMETIMES
- NOT YET
3. Does your baby feed himself a cracker or a cookie?*
- YES
- SOMETIMES
- NOT YET
4. When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn’t let go of it? (If she already lets go of the toy into your hand, mark “yes” for this item.)*
- YES
- SOMETIMES
- NOT YET
5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?*
- YES
- SOMETIMES
- NOT YET
6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?*
- 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:*