ASQ48month

Child's First Name

Child's Middle Initial

Child's Last Name

Child's Date of Birth

Gender

First Name

Middle Initial

Last Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Other Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Relationship to child

Other

People Assisting Questionnaire Completion

Type a question

Rows	Often or Always	Sometimes	Rarely or Never	Checck if this is a concern
1. Does your child look at you when you talk to him/her?
2. Does your child cling to you more than you expect?
3. Does your child talk or play with adults he/she knows well?
4. When upset, can your child calm him/herself down within 15 minuets?
5. does your child like to be hugged or cuddled?
6. does your child seem too friendly with strangers?
7. Does your child settle him/herself down after exciting activities?
8. Does your child cry, scream, or have tantrums for long periods of time?
9. Does your child seem interested in things around him/her such as people, toys, and foods?
10. Does your child stay dry during the day?
111. Does your child have eating problems? For example, does he/she stuff food, vomit, eat things that are not food, or_____? (Please describe below)
12. Do you and your child enjoy mealtimes together?
13. Does your child do what you ask him/her to do?
14. Does your child seem happy?
15. Does your child sleep at least 8 hours in a 24 hour period?
16. Does your child seem more active than other children their age?
17. Does your child use words to tell you what he/she wants?
18. Does your child stay with activities he/she enjoys for at least 10 minuets? (other than watching shows or videos, or playing with electronics)
19. Does yourchild use words to describe their feelings and the feelings of others? For example, do they say, "i'm happy", "I don't like that", or "she's sad"
20. Does your child move from one activity to the next with little difficulty? (for example, from playtime to mealtime)
21. Does your child explore new places, such as a par or a friends home?
22. Does your child do things over and over and get upset when you try to stop him? For example, does he/she rock, flip his/her hands. spin, or ____? (Please describe below)
23. Does your child hurt him/herself on purpose?
24. Does your child follow rules at home or at child care?
25. Does your child destroy or damage things on purpose?
26. Does your child stay away from dangerous things, such as fire and moving cars?
27. Can your child name a friend?
28. Does your child show concern for other people's feelings? For example, does he/she look sad when someone is hurt?
29. Do other children like to play with your child?
30. Does your child like to play with other children?
31. Does your child try to hurt other children, adults, or animals?(for example, by kicking or biting)
32. Does your child show an unusual interest or knowledge of sexual language or activity?
33. Does your child wake three or more times during the night?
34. Is your child too worried or fearful? If "Sometimes" or "often or always" please describe below.
35. Does your child have simple back and forth conversations with you? for example, Parent: "it's raining" child: "and cold outside" Parent: "let's get your coat" child: "I got it"
36. Has anyone shared concerns about your child's behaviors? If "Sometimes" or "often or always" please explain below

Please Describe from question 11

Please describe form question 22

Please describe from question 34

Please describe from question 36

Do you have concerns about your child's eating, sleeping, or toileting habits? If yes, Please explain below.

If yes, please explain

Does anything about your child worry you? If yes, please explain below

If yes, please explain

What do you enjoy about your child?

Child's Information

Person filling out questionnaire