ASQ-3: 27-Month Questionnaire E/S

ASQ-3: Ages & Stages Questionnaires® - 27 Month Questionnaire

25 months 16 days through 28 months 15 days
Which clinic would you prefer?
Date ASQ completed:

MonthDayYear
Date
Child's information
Child's name:

First NameMiddle InitialLast Name
Child's date of birth:

MonthDayYear
Date
Child's gender:
Person filling out questionnaire
Name:

First NameMiddle InitialLast Name
Relationship to child:

Other
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home telephone number:
Please enter a valid phone number.Format: (000) 000-0000.
Other telephone number:
Please enter a valid phone number.Format: (000) 000-0000.
Email address:
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:
COMMUNICATION
1. Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?
Which directions did your child complete?
2. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, “What is this?” does your child correctly name at least one picture?
3. When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark “sometimes” if she correctly points to at least three different body parts.)
4. Does your child correctly use at least two words like “me,” “I,” “mine,” and “you”?
5. Does your child make sentences that are three or four words long?
Please give an example:
6. Without giving your child help by pointing or using gestures, ask him to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly?
GROSS MOTOR
1. Does your child walk either up or down at least two steps by himself? He may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
2. Does your child run fairly well, stopping herself without bumping into things or falling?
3. Does your child jump with both feet leaving the floor at the same time?
4. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
5. Does your child jump forward at least 3 inches with both feet leaving the ground at the same time?
6. Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall.
FINE MOTOR
1. Does your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?
2. Does your child flip switches off and on?
3. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction?
4. Does your child stack seven small blocks or toys on top of each other by herself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)
5. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
6. After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction?
PROBLEM SOLVING
1. Does your child pretend objects are something else? For example, does your child hold a cup to his ear, pretending it is a telephone? Does he put a box on her head, pretending it is a hat? Does he use a block or small toy to stir food?
2. Does your child put things away where they belong? For example, does she know her toys belong on the toy shelf, her blanket goes on her bed, and dishes go in the kitchen?
3. When looking in the mirror, ask “Where is _______?” (Use your child’s name.) Does your child point to his image in the mirror?
4 . If your child wants something she cannot reach, does she find a chair or box to stand on to reach it (for example, to get a toy on a counter or to “help” you in the kitchen)?
5. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.)
6. When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”)
Please write your child’s response here:
PERSONAL-SOCIAL
1. If you do any of the following gestures, does your child copy at least one of them?
What gestures does your child copy?
2. Does your child eat with a fork?
3. When playing with either a stuffed animal or a doll, does your child pretend to rock it, feed it, change its diapers, put it to bed, and so forth?
4. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if he cannot turn?
5. Does your child call herself “I” or “me” more often than her own name? For example, “I do it” more often than “Juanita do it.”
6. Does your child put on a coat, jacket, or shirt by himself?
OVERALL

Parents and providers may use the space below for additional comments.
1. Do you think your child hears well?
If no, explain:
2. Do you think your child talks like other toddlers her 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 his 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 any 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:
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:
Should be Empty:

ASQ-3: Ages & Stages Questionnaires® - 27 Month Questionnaire

Child's information

Person filling out questionnaire

COMMUNICATION

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL