30 Month ASQ
  • 30 Month ASQ

    30 Month ASQ

    Ages & Stages Questionnaire

  • Please provide the following information. 

  • Child's gender
  • Child's date of birth
     / /

  • The person filling out questionnaire

  • Relationship to child
  • Format: (000) 000-0000.

  • Important Points to Remember

    * 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 before your next appointment.

  • 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?
  • If Yes or Sometimes, please pick the ones that apply:
  • 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 make sentences that are three or four words long? Please give an example
  • 5. 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?
  • 6. When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, "barking," "running, "eating," or "crying")? You may ask, "What is the dog (or boy) doing?'
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  • GROSS MOTOR

  • 1. Does your child run fairly well, stopping herself without bumping into things or falling?
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  • 2.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.)
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  • 3. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
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  • 4. Does your child jump with both feet leaving the floor at the same time?
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  • 5. Does your child walk upstairs, 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.
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  • 6. Does your child stand on one foot for about 1 second without holding onto anything?
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  • 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. 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?
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  • 3.Can your child string small items such as beads, macaroni, or pasta "wagon wheels' onto a string or shoelace?
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  • 4. 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?
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  • 5. After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?
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  • 6. Does your child turn pages in a book, one page at a time?

  • PROBLEM SOLVING

  • 1. When looking in the mirror, ask, "Where is (Use your child's name Does your child point to her image in the mirror?)
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  • 2.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)?
  • 3. 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
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  • 4. 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. ")
  • 5.When you say, "Say 'seven three," does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, "Say 'eight two."" Your child must repeat just one series of two numbers for you to answer "yes" to this question.
  • 6. After your child draws a "picture," even a simple scribble, does she tell you what she drew? (You may say, "Tell me about your picture," or ask, "What is this?' to prompt her

  • PERSONAL-SOCIAL

  • 1a) . If you do any of the gestures show in question 1b below, does your child copy at least one of them?
  • 1b. Please pick the gestures your child is copying:
  • 2. Does your child use a spoon to feed himself with little spilling?
  • 3. Does your child push a little wagon, stroller, or other toys on wheels, steering it around objects and backing out of corners if she cannot turn?
  • 4. Does your child put on a coat, jacket, or shirt by himself?
  • 5. After you put on loose-fitting pants around her feet, does your child pull them completely up to her waist?
  • 6. When your child is looking in a mirror and you ask, "Who is in the mirror?" does he say either "me" or his own name?

  • OVERALL

  • Parents and providers may use the space below for additional comments.

  • 1 Do you think your child hears well? If no, click on other and explain:
  • 2. Do you think your child talks like other toddlers her age? If no, click on other and explain:
  • 3. Can you understand most of what your child says? If no click on others and explain:
  • 4. Can other people understand most of what your child says? If no, explain
  • 5. Do you think your child walks, runs, and climbs like other toddlers his age? If no click on other and explain:
  • 6. Does either parent have a family history of childhood deafness or hearing impairment? If yes, click on other and explain
  • 7. Do you have any concerns about your child's vision? If yes, click on other and explain
  • 8. Has your child had any medical problems in the last several months? If yes, explain
  • 9. Do you have any concerns about your child's behavior? If yes, click on other and explain
  • 10. Does anything about your child worry you? If yes, click on Other and explain

  • Ages & Stages Questionnaires®, Third Edition (ASQ-3T), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved.

  • The END

    Please click the green "Submit" button below to finish and send your answer to the office. Thank you.
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