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ASQ-3 - Sample

ASQ-3 - Sample - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
2009 Paul H. Br ookes Publishing Co. All rights reserved.P101160100
Person filling out questionnaire
Child’s information
Date ASQ completed:
Relationship to child:
Parent
Street address:
Names of people assisting in questionnaire completion:
Grandparent
or other
relative
Guardian
Foster
parent
Teacher
Child care
provider
Other:
Ages & Stages
Questionnaires
®
Month Questionnaire
15 months 0 days through 16 months 30 days
Please provide the following information. Use black or blue ink only and print
legibly when completing this form.
16
Child’s first name: Child’s last name:
Child’s date of birth:
First name:
Last name:
Middle
initial:
City:
Home
telephone
number:
State/
Province:
ZIP/
Postal code:
Other
telephone
number:
E-mail address:
If child was born 3
or more weeks
prematurely, # of
weeks premature:
Child’s gender:
Male Female
Middle
initial:
Country:
Program Information
Age at administration in months and days:Child ID #:
Program ID #:
Program name:
If premature, adjusted age in months and days:
6222001439183664
9/20/2008
Annie M. Roberts
5/5/2007
Jennifer M. Roberts
33 Main Street
Jonestown IN 61924
USA 219-888-0021 219-912-2100
36759111023412358 16 months, 15 days
jennifer
roberts@email.com
Jonestown Child Care Center
S
A
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At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your
child more than one time. If possible, try the activities when your child is cooperative. If your child can do the activity but refuses,
mark “yes” for the item.
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
2009 Paul H. Br ookes Publishing Co. All rights reserved.
page 2 of 6
E101 160200
Month Questionnaire
16
15 months 0 days
through 16 months 30 days
Important Points to Remember:
Try each activity with your baby before marking a response.
Make completing this questionnaire a game that is fun for
you and your child.
Make sure your child is rested and fed.
Please return this questionnaire by _______________.
Notes:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
On the following pages are questions about activities babies may do. Your baby may have already done some of the activities
described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indi-
cates whether your baby is doing the activity regularly, sometimes, or not yet.
COMMUNICATION
1. Does your child point to, pat, or try to pick up pictures in a book?
2. Does your child say four or more words in addition to “Mama” and
“Dada”?
3. When your child wants something, does she tell you by pointing to it?
4. When you ask your child to, does he go into another room to find a fa-
miliar toy or object? (You might ask, “Where is your ball?” or say,
“Bring me your coat,” or “Go get your blanket.”)
5. Does your child imitate a two-word sentence? For example, when you
say a two-word phrase, such as “Mama eat,” “Daddy play,” “Go
home,” or “What’s this?” does your child say both words back to you?
(Mark “yes” even if her words are difficult to understand.)
6. Does your child say eight or more words in addition to “Mama” and
“Dada”?
GROSS MOTOR
1. Does your child stand up in the middle of the floor by himself and take
several steps forward?
2. Does your child climb onto furniture or other large objects, such as
large climbing blocks?
3. Does your child bend over or squat to pick up an object from the floor
and then stand up again without any support?
YES SOMETIMES NOT YET
COMMUNICATION TOTAL
YES SOMETIMES NOT YET
S
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5
10
10
10
10
10
55
5
10
10

GROSS MOTOR (continued)
4. Does your child move around by walking, rather than crawling on her
hands and knees?
5. Does your child walk well and seldom fall?
6. Does your child climb on an object such as a chair to reach something
he wants (for example, to get a toy on a counter or to “help” you in the
kitchen)?
FINE MOTOR
1. Does your child help turn the pages of a book? (You may lift a page for
her to grasp.)
2. Does your child throw a small ball with a forward arm motion?
(If he simply drops the ball, mark “not yet” for this item.)
3. Does your child stack a small block or toy on top of another one? (You
could also use spools of thread, small boxes, or toys that are about 1
inch in size.)
4. Does your child stack three small blocks or toys on top of each other by
herself?
5. Does your child make a mark on the paper with the tip
of a crayon (or pencil or pen) when trying to draw?
6. Does your child turn the pages of a book by himself? (He may turn
more than one page at a time.)
PROBLEM SOLVING
1. After you scribble back and forth on paper with a crayon (or pencil or
pen), does your child copy you by scribbling? (If she already scribbles
on her own, mark “yes” for this item.)
2. Can your child drop a crumb or Cheerio into a small, clear bottle (such
as a plastic soda-pop bottle or baby bottle)?
3. Does your child drop several small toys, one after another, into a con-
tainer like a bowl or box? (You may show him how to do it.)
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
2009 Paul H. Br ookes Publishing Co. All rights reserved.
16 Month Questionnaire page 3 of 6
E101 160300
YES SOMETIMES NOT YET
GROSS MOTOR TOTAL
YES SOMETIMES NOT YET
FINE MOTOR TOTAL
YES SOMETIMES NOT YET
S
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5
10
10
0
40
5
10
10
5
0
40
5
5
10

PROBLEM SOLVING (continued)
4. After you have shown your child how, does she try to get
a small toy that is slightly out of reach by using a spoon,
stick, or similar tool?
5. Without your showing him how, does your child scribble back and forth
when you give him a crayon (or pencil or pen)?
6. After a crumb or Cheerio is dropped into a small, clear bottle, does
your child turn the bottle upside down to dump it out? (You may show
her how.)
PERSONAL-SOCIAL
1. Does your child feed himself with a spoon, even though he may spill
some food?
2. Does your child help undress herself by taking off clothes like socks,
hat, shoes, or mittens?
3. Does your child play with a doll or stuffed animal by hugging it?
4. While looking at himself in the mirror, does your child offer a toy to his
own image?
5. Does your child get your attention or try to show you something by
pulling on your hand or clothes?
6. Does your child come to you when she needs help, such as with wind-
ing up a toy or unscrewing a lid from a jar?
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
2009 Paul H. Br ookes Publishing Co. All rights reserved.
16 Month Questionnaire page 4 of 6
E101 160400
YES SOMETIMES NOT YET
PROBLEM SOLVING TOTAL
*If Problem Solving Item 5 is marked
“yes,” mark Problem Solving
Item 1 as “yes.”
YES SOMETIMES NOT YET
PERSONAL-SOCIAL TOTAL
OVERALL
Parents and providers may use the space below for additional comments.
1. Do you think your child hears well? If no, explain: YES NO
*
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10
10
10
5
45
10
10
0
10
10
50

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
2009 Paul H. Br ookes Publishing Co. All rights reserved.
16 Month Questionnaire page 5 of 6
E101 160500
OVERALL (continued)
2. Do you think your child talks like other toddlers his age? If no, explain:
3. Can you understand most of what your child says? If no, explain:
4. Do you think your child walks, runs, and climbs like other toddlers her age?
If no, explain:
5. Does either parent have a family history of childhood deafness or hearing
impairment? If yes, explain:
6. Do you have concerns about your child’s vision? If yes, explain:
7. Has your child had any medical problems in the last several months? If yes, explain:
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
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Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
2009 Paul H. Br ookes Publishing Co. All rights reserved.
16 Month Questionnaire page 6 of 6
E101 160600
OVERALL (continued)
8. Do you have any concerns about your child’s behavior? If yes, explain:
9. Does anything about your child worry you? If yes, explain:
YES NO
YES NO
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Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
2009 Paul H. Br ookes Publishing Co. All rights reserved.P101160700
3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall
responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
If the child’s total score is in the area, it is above the cutoff, and the child’s development appears to be on schedule.
If the child’s total score is in the area, it is close to the cutoff. Provide learning activities and monitor.
If the child’s total score is in the area, it is below the cutoff. Further assessment with a professional may be needed.
Child’s name: ________________________________________________________
Child’s ID #: ______________________________________________________
Administering program/provider:
seY?llew sraeH.1 NO
Comments:
2. Talks like other toddlers his age? Yes NO
Comments:
3. Understand most of what your child says? Yes NO
Comments:
4. Walks, runs, and climbs like other toddlers? Yes NO
Comments:
5. Family history of hearing impairment? YES No
Comments:
Date ASQ completed: __________________________________________
Date of birth: ______________________________________________
Was age adjusted for prematurity
when selecting questionnaire? Yes No
Month ASQ-3 Information Summary
16
15 months 0 days through
16 months 30 days
Communication
Gross Motor
Fine Motor
Problem Solving
Personal-Social
123456
2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.
6. Concerns about vision? YES No
Comments:
7. Any medical problems? YES No
Comments:
8. Concerns about behavior? YES No
Comments:
9. Other concerns? YES No
Comments:
1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User’s Guide for details, including how to adjust scores if item
responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.
In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.
Communication
Gross Motor
Fine Motor
Problem Solving
Personal-Social
0 5 10 15 20 25 30 35 40 45 50 55 60
Total
Area Cutoff Score
16.81
37.91
31.98
30.51
26.43
4. FOLLOW-UP ACTION TAKEN: Check all that apply.
______ Provide activities and rescreen in _____ months.
______ Share results with primary health care provider.
______ Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
______ Refer to primary health care provider or other community agency (specify
reason): __________________________________________________________.
______ Refer to early intervention/early childhood special education.
______ No further action taken at this time
______ Other (specify): ____________________________________________________
5. OPTIONAL: Transfer item responses
(Y = YES, S = SOMETIMES, N = NOT YET,
X = response missing).
9/20/2008Annie M. Roberts
5/5/2007
S
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36759111023412358
Jonestown Child
Care Center
55
40
40
45
50
Y Y Y Y Y S
Y S Y Y S N
S Y Y Y S N
S S Y Y S Y
Y Y Y N Y Y