ASQ-3: 22-Month Questionnaire E/S

ASQ-3: Ages & Stages Questionnaires® - 22 Month Questionnaire

21 months 0 days through 22 months 30 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
If child was born 3 or more weeks prematurely, # of weeks premature:
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. 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?
2. 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?
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 say 15 or more words in addition to “Mama” and “Dada”?
5. Does your child correctly use at least two words like “me,” “I,” “mine, ”and “you”?
6. Does your child say two or three words that represent different ideas together, such as “See dog,” “Mommy come home,” or “Kitty gone”? (Don’t count word combinations that express one idea, such as “bye-bye,” “all gone,” “all right,” and “What’s that?”)
Please give an example of your child’s word combinations:
GROSS MOTOR
1. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (If your child already kicks a ball, mark “yes” for this item.)
2. Does your child run fairly well, stopping herself without bumping into things or falling?
3. Does your child walk down stairs if you hold onto one of his hands? He may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
4. Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wall.
5. Does your child jump with both feet leaving the floor at the same time?
6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
FINE MOTOR
1. Does your child get a spoon into his mouth right side up so that the food usually doesn’t spill?
2. Does your child stack six small blocks or toys on top of each other by himself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)
3. Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?
4. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)
5. Does your child flip switches off and on?
6. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
PROBLEM SOLVING
1. Without your showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)?
2. 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 at least two blocks side by side? (You can also use spools of thread, small boxes, or other toys.)
3. Does your child pretend objects are something else? For example, does your child hold a cup to her ear, pretending it is a telephone? Does she put a box on her head, pretending it is a hat? Does she use a block or small toy to stir food?
4 . After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark “not yet” if your child scribbles back and forth.)
5. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump out the crumb or Cheerio? (Do not show her how.)(You can use a soda-pop bottle or a baby bottle.)
6. If you give your child a bottle, spoon, or pencil upside down, does he turn it right side up so that he can use it properly?
PERSONAL-SOCIAL
1. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?
2. If you do any of the following gestures, does your child copy at least one of them?
3. Does your child eat with a fork?
4. Does your child drink from a cup or glass, putting it down again with little spilling?
5. 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?
6. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she cannot turn?
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® - 22 Month Questionnaire

Child's information

Person filling out questionnaire

COMMUNICATION

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL