ASQ 6 months
Child's Name
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First Name
Last Name
Parent/Guardian filling out form
*
First Name
Last Name
Email
*
example@example.com
Child's Birthday
*
/
Month
/
Day
Year
Date
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Communication Section
Does your baby make high-pitched squeals?
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Yes
Sometimes
Not yet
When playing with sounds, does your baby make grunting, growling, or other deep-toned sounds?
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Sometimes
Yes
Not yet
If you call your baby when you are out of sight, do they look in the direction of your voice?
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Yes
Sometimes
Not yet
When a loud noise occurs, does your baby turn to see where the sound came from?
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Yes
Sometimes
Not yet
Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?
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Yes
Sometimes
Not yet
If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?
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Yes
Sometimes
Not yet
Score For Communication Section
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Gross Motor
While your baby is on their back, does your baby lift their legs high enough to see their feet?
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Yes
Sometimes
Not yet
When your baby is on their tummy, do they straighten both arms and push their whole chest off the bed or floor?
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Yes
Sometimes
Not yet
Does your baby roll from their back to their tummy, getting both arms out from under them?
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Yes
Sometimes
Not yet
When you put your baby on the floor, do they lean on their hands while sitting? (If they already sit up straight without leaning on their hands, mark “yes” for this item.)
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Yes
Sometimes
Not yet
If you hold both hands just to balance your baby, do they support their own weight while standing?
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Yes
Sometimes
Not yet
Does your baby get into a crawling position by getting up on their hands and knees?
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Yes
Sometimes
Not yet
Score For Gross Motor Section
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Fine Motor
Does your baby grab a toy you offer and look at it, wave it about, or chew on it for about 1 minute?
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Yes
Sometimes
Not yet
Does your baby reach for or grasp a toy using both hands at once?
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Yes
Sometimes
Not Yet
Does your baby reach for a crumb or Cheerio and touch it with their finger or hand? (If they already pick up a small object the size of a pea, mark “yes” for this item.)
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Yes
Sometimes
Not yet
Does your baby pick up a small toy, holding it in the center of their hand with their fingers around it?
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Yes
Sometimes
Not yet
Does your baby try to pick up a crumb or Cheerio by using their thumb and all of their fingers in a raking motion, even if they aren't able to pick it up? (If they already pick up the crumb or Cheerio, mark “yes” for this item.)
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Yes
Sometimes
Not yet
Does your baby pick up a small toy with only one hand?
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Yes
Sometimes
Not yet
Score for Fine Motor section
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Problem Solving
When a toy is in front of your baby, do they reach for it with both hands?
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Yes
Sometimes
Not yet
When your baby is on their back, do they turn their head to look for a toy when they drop it? (If they already picks it up, mark “yes” for this item.)
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Yes
Sometimes
Not yet
When your baby is on their back, do they try to get a toy they have dropped if they can see it?
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Yes
Sometimes
Not yet
Does your baby pick up a toy and put it in their mouth?
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Yes
Not yet
Does your baby pass a toy back and forth from one hand to the other?
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Yes
Sometimes
Not yet
Does your baby play by banging a toy up and down on the floor or table?
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Yes
Sometimes
Not yet
Score for Problem Solving Section
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Personal-Social
When in front of a large mirror, does your baby smile or coo at themself?
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Yes
Sometimes
Not yet
Does your baby act differently toward strangers than they do with you and other familiar people? (Reactions to strangers may include staring, frowning, withdrawing, or crying.)
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Yes
Sometimes
Not yet
While lying on their back, does your baby play by grabbing their foot?
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Yes
Sometimes
Not yet
When in front of a large mirror, does your baby reach out to pat the mirror?
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Yes
Sometimes
Not yet
While your baby is on their back, do they put their foot in their mouth?
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Yes
Sometimes
Not yet
Does your baby try to get a toy that is out of reach? (They may roll, pivot on their tummy, or crawl to get it.)
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Yes
Sometimes
Not yet
Score for Personal-Social section
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Overall
Does your baby use both hands and both legs equally well? If no, explain:
If yes, leave blank. If no, explain.
When you help your baby stand, are their feet flat on the surface most of the time? If no, explain:
If yes, leave blank. If no, explain.
Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:
If yes, leave blank. If no, explain.
Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:
If no, leave blank. If yes, explain.
Do you have concerns about your baby’s vision? If yes, explain:
If no, leave blank. If yes, explain.
Has your baby had any medical problems in the last several months? If yes, explain:
If no, leave blank. If yes, explain.
Do you have any concerns about your baby’s behavior? If yes, explain:
If no, leave blank. If yes, explain.
Does anything about your baby worry you? If yes, explain:
If no, leave blank. If yes, explain.
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