ASQ-3: 20-Month Questionnaire E/S

ASQ-3: Ages & Stages Questionnaires® - 20 Month Questionnaire

19 months 0 days through 20 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. 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.)
2. Does your child say eight or more words in addition to “Mama” and “Dada”?
3. Without your showing him, does your child point to the correct picture when you say, “Show me the kitty,” or ask, “Where is the dog?” (He needs to identify only one picture correctly.)
4. 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?
5. 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?
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. 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)?
2. Does your child walk well and seldom fall?
3. Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
4. 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.)
5. Does your child run fairly well, stopping herself without bumping into things or falling?
6. Does your child walk either up or down at least two steps by himself? He may also hold onto the railing or wall.
FINE MOTOR
1. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?
2. Does your child stack three 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.)
3. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)
4. Does your child get a spoon into her mouth right side up so that the food usually doesn’t spill?
5. Does your child stack six small blocks or toys on top of each other by himself?
6. 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?
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. 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.)
3. If you do any of the following gestures, does your child copy at least one of them?
4 . If you give your child a bottle, spoon, or pencil upside down, does she turn it right side up so that she can use it properly?
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 at least two blocks side by side?(You can also use spools of thread, small boxes, or other toys.)
6. If your child wants something he cannot reach, does he 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)?
PERSONAL-SOCIAL
1. Does your child feed herself with a spoon, even though she may spill some food?
2. Does your child get your attention or try to show you something by pulling on your hand or clothes?
3. Does your child drink from a cup or glass, putting it down again with little spilling?
4. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?
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 eat with a fork?
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® - 20 Month Questionnaire

Child's information

Person filling out questionnaire

COMMUNICATION

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL