ASQ-3: 60-Month Questionnaire E/S

Which clinic would you prefer? *

Date ASQ completed:

Date

Child's name: *

First Name Middle Initial Last Name

Child's date of birth: *

Date

Child's gender: *

Male Female

Name: *

First Name Middle Initial Last Name

Relationship to child:

Parent Guardian Teacher Child care provider Grandparent or other relative Foster parent Other

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home telephone number: *

Please enter a valid phone number.

Other telephone number:

Please enter a valid phone number.

Email

example@example.com

Names of people assisting in questionnaire completion:

On the following pages are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please fill in the circle that indicates whether your child is doing the activity regularly, sometimes, or not yet.

Try each activity with your child 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 24 hours prior to your appointment.

Notes:

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 write 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"?

Yes Sometimes Not Yet

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.") Please write an example:

4. Does your child use comparison words, such as "heavier," "stronger," or "shorter"?

Yes Sometimes Not Yet

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). Please write an example:

5. Does your child answer the following questions? (Mark "sometimes" if your child answers only one question.)

Yes Sometimes Not Yet

"What do you do when you are hungry?" (Acceptable answers include "get food," "eat," "ask for something to eat," and "have a snack.") Please write your child's response:

"What do you do when you are tired?" (Acceptable answers include: "take a nap," "rest," "go to sleep," "lie down," and "sit down." Please write your child's response:

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.) - (a) Jane hides her shoes for Maria to find. - (b) Al read the blue book under his bed.

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.")

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.)

Yes Sometimes Not Yet

3. Without holding onto anything, does your child stand on one foot 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.)

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.)

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.)

Yes Sometimes Not Yet

1. Ask your child to trace on the line below 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 on a blank sheet of paper. 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." Be sure to include the sheet of paper with your child's drawing with this questionnaire or bring to your appointment.

Yes Sometimes Not Yet

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 god 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 copied all three shapes; mark "sometimes" if your child copies two shapes.)

Yes Sometimes Not Yet

(Space for child's shapes)

5. Using the letters below to look at,

Yes Sometimes Not Yet

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 up 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 italicized? 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.) Please write your child's responses below:

Yes Sometimes Not Yet

A cow is big, and a mouse is

Ice is cold, and fire is

We see stars at night, and we see the sun during the

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.)

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.)

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?

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?

Yes Sometimes Not Yet

3. Does your child tell you at least four of the following?

Yes Sometimes Not Yet

Please mark the items your child knows.

First name Last name Age Boy or girl City he lives in Telephone number

4. Does your child dress and undress himself, including buttoning medium-size buttons and zipping front zippers?

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.

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

If no, explain:

2. Do you think your child talks like other children her age?

Yes No

If no, explain:

3. Can you understand most of what your child says?

Yes No

If no, explain:

4. Can other people understand most of what your child says?

Yes No

If no, explain:

5. Do you think your child walks, runs, and climbs like other children his age?

Yes No

If no, explain:

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

Yes No

If yes, explain:

7. Do you have any concerns about your child's vision?

Yes No

If yes, explain:

8. Has your child had any medical problems in the last several months?

Yes No

If yes, explain:

9. Do you have any concerns about your child's behavior?

Yes No

If yes, explain:

10. Does anything about your child worry you?

Yes No

If yes, explain:

ASQ-3: Ages & Stages Questionnaires® - 60 Month Questionnaire

Child's information

Person filling out questionnaire

Communication

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL