18 Month ASQ Questionnaire

Please provide the following information.

Child's first name*

Middle initial

Last Name*

Child's date of birth*

Date

If child was born 3 or more weeks prematurely, # of weeks premature

Child's gender*

MaleFemale

Relationship to child*

Person filling out questionnaire

Name*

First nameMiddle initialLast name

Street address

Home telephone number

Mobile number*

Email address*

example@example.com

Names of people assisting in questionnaire completion

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities
described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

17 months 0 days through 18 months, 30 days

Important Points to Remember:
✓ Try each activity with your baby 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.

Would you like to add a Note:

At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your child more than one time. If possible, try the activities when your child is cooperative. If your child can do the activity but refuses, mark "yes" for the item.

1.When your child wants something, does she tell you by pointing to it?*

YesSometimesNot Yet

2. When you ask your child to, does he go into another room to find a familiar toy or object? (You might ask, "Where is your ball?" or say, "Bring me your coat,' or "Go get your blanket. ")*

YesSometimesNot Yet

3. Does your child say eight or more words in addition to "Mama" and "Dada"?*

YesSometimesNot Yet

4. 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.)*

YesSometimesNot Yet

5. 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.)*

YesSometimesNot Yet

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 ex- ample of your child's word combinations:*

YesSometimesNot Yet

1.Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?*

YesSometimesNot Yet

2. Does your child move around by walking, rather than by crawling on her hands and knees?*

YesSometimesNot Yet

3. Does your child walk well and seldom fall?*

YesSometimesNot Yet

4. 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)?*

YesSometimesNot Yet

5. 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.)*

YesSometimesNot Yet

6. 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.)*

YesSometimesNot Yet

1. Does your child throw a small ball with a forward arm motion? (If he simply drops the ball, mark "not yet" for this item.)*

YesSometimesNot Yet

2. Does your child stack a small block or toy on top of another one? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)*

YesSometimesNot Yet

3. Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?*

YesSometimesNot Yet

4. Does your child stack three small blocks or toys on top of each other by himself?*

YesSometimesNot Yet

5. Does your child turn the pages of a book by himself? (He may turn more than one page at a time*

YesSometimesNot Yet

6. Does your child get a spoon into her mouth right side up so that the food usually doesn't spill?*

YesSometimesNot Yet

1. Does your child drop several small toys, one after another, into a container like a bowl or box? (You may show him how to do it.)*

YesSometimesNot Yet

2. After you have shown your child how, does she try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?*

YesSometimesNot Yet

3. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle over to dump it out? (You may show him how (You can use a soda-pop bottle or a baby bottle.)*

YesSometimesNot Yet

4. Without your showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)?*

YesSometimesNot Yet

5. After watching you draw a line from the top of theelll paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on Count as "not yet" the paper in any direction? (Mark "not yet" if your child scribbles back and forth*

YesSometimesNot Yet

6. After a crumb or Cheerio is dropped into a small, clear bottle, doesyour child turn the bottle upside down to dump out the crumb orCheerio? (Do not show him how.)*

YesSometimesNot Yet

1. While looking at herself in the mirror, does your child offer a toy to her own image?*

YesSometimesNot Yet

2. Does your child play with a doll or stuffed animal by hugging it?*

YesSometimesNot Yet

3. Does your child get your attention or try to show you something by pulling on your hand or clothes?*

YesSometimesNot Yet

4. Does your child come to you when he needs help, such as with winding up a toy or unscrewing a lid from a jar?*

YesSometimesNot Yet

5. Does your child drink from a cup or glass, putting it down again with little spilling?*

YesSometimesNot Yet

6. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?*

YesSometimesNot Yet

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

1. Do you think your child hears well?*

YesNo, please explain:

2. Do you think your child talks like other toddlers his age? *

YesNo, please explain:

3. Can you understand most of what your child says?*

YesNo, please explain:

4. Do you think your child walks, runs, and climbs like other toddlers her age?*

YesNo, please explain:

5. Does either parent have a family history of childhood deafness or hearing impairment?*

NoYes, please explain:

6. Do you have concerns about your child's vision?*

NoYes, please explain:

7. Has your child had any medical problems in the last several months?*

NoYes, please explain:

8. Do you have any concerns about your child's behavior?*

NoYes, please explain:

9. Does anything about your child worry you?*

NoYes, please explain:

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