ASQ-3 – 09 Month Questionnaire

9 MONTH ASSESSMENT

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PATIENT NAME*

First Last

DATE OF BIRTH*

Month

Day

Year

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MRN

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

Please explain:*

2. When you help your baby stand, are his feet flat on the surface most of the time?*

YES

Please explain:*

3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*

YES

Please explain:*

4. Does either parent have a family history of childhood deafness or hearing impairment?*

YES

Please explain:*

5. Do you have concerns about your baby’s vision*

YES

Please explain:*

6. Has your baby had any medical problems in the last several months?*

YES

Please explain:*

7. Do you have any concerns about your baby’s behavior?*

YES

Please explain:*

8. Does anything about your baby worry you?*

YES

Please explain:*