ASQ-3: 2-Month Questionnaire E/S

ASQ-3: Ages & Stages Questionnaires® - 2 Month Questionnaire

1 months 0 days through 2 months 30 days
Which clinic would you prefer?*
Date ASQ completed:

MonthDayYear
Date
Baby's information
Baby's name:*

First NameMiddle InitialLast Name
Baby's date of birth:*

MonthDayYear
Date
If baby was born 3 or more weeks prematurely, # of weeks premature:
Baby's gender:*

MaleFemale
Person filling out questionnaire
Name:*

First NameMiddle InitialLast Name
Relationship to baby:

ParentGuardianTeacherChild care providerGrandparent or other relativeFoster parentOther
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home telephone number:*
Please enter a valid phone number.
Other telephone number:
Please enter a valid phone number.
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 baby sometimes make throaty or gurgling sounds?

YesSometimesNot Yet
2. Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?

YesSometimesNot Yet
3. When you speak to your baby, does she make sounds back to you?

YesSometimesNot Yet
4. Does your baby smile when you talk to him?

YesSometimesNot Yet
5. Does your baby chuckle softly?

YesSometimesNot Yet
6. After you have been out of sight, does your baby smile or get excited when she sees you?

YesSometimesNot Yet
GROSS MOTOR
1. While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?

YesSometimesNot Yet
2. When your baby is on her tummy, does she turn her head to the side?

YesSometimesNot Yet
3. When your baby is on his tummy, does he hold his head up longer than a few seconds?

YesSometimesNot Yet
4. When your baby is on her back, does she kick her legs?

YesSometimesNot Yet
5. While your baby is on his back, does he move his head from side to side?

YesSometimesNot Yet
6. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?

YesSometimesNot Yet
FINE MOTOR
1. Is your baby’s hand usually tightly closed when he is awake? (If your baby used to do this but no longer does, mark “yes.”)

YesSometimesNot Yet
2. Does your baby grasp your finger if you touch the palm of her hand?

YesSometimesNot Yet
3. When you put a toy in his hand, does your baby hold it in his hand briefly?

YesSometimesNot Yet
4. Does your baby touch her face with her hands?

YesSometimesNot Yet
5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?

YesSometimesNot Yet
6. Does your baby grab or scratch at her clothes?

YesSometimesNot Yet
PROBLEM SOLVING
1. Does your baby look at objects that are 8–10 inches away?

YesSometimesNot Yet
2. When you move around, does your baby follow you with his eyes?

YesSometimesNot Yet
3. When you move a toy slowly from side to side in front of your baby’s face (about 10 inches away), does your baby follow the toy with her eyes, sometimes turning her head?

YesSometimesNot Yet
4 . When you move a small toy up and down slowly in front of your baby’s face (about 10 inches away), does your baby follow the toy with his eyes?

YesSometimesNot Yet
5. When you hold your baby in a sitting position, does she look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of her?

YesSometimesNot Yet
6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?

YesSometimesNot Yet
PERSONAL-SOCIAL
1. Does your baby sometimes try to suck, even when she’s not feeding?

YesSometimesNot Yet
2. Does your baby cry when he is hungry, wet, tired, or wants to be held?

YesSometimesNot Yet
3. Does your baby smile at you?

YesSometimesNot Yet
4. When you smile at your baby, does she smile back?

YesSometimesNot Yet
5. Does your baby watch his hands?

YesSometimesNot Yet
6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?

YesSometimesNot Yet
OVERALL

Parents and providers may use the space below for additional comments.
1. Did your baby pass the newborn hearing screening test?

YesNo
If no, explain:
2. Does your baby move both hands and both legs equally well?

YesNo
If no, explain:
3. Does either parent have a family history of childhood deafness, hearing impairment, or vision problems?

YesNo
If yes, explain:
4. Has your baby had any medical problems?

YesNo
If yes, explain:
5. Do you have concerns about your baby’s behavior (for example, eating, sleeping)?

YesNo
If yes, explain:
6. Does anything about your baby worry you?

YesNo
If yes, explain:
Should be Empty:

ASQ-3: Ages & Stages Questionnaires® - 2 Month Questionnaire

Baby's information

Person filling out questionnaire

COMMUNICATION

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL