ASQ 2 months
Child's Name
*
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 sometimes make throaty or gurgling sounds?
*
Sometimes
Yes
Not yet
Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?
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Yes
Sometimes
Not yet
When you speak to your baby, does she make sounds back to you?
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Yes
Sometimes
Not yet
Does your baby smile when you talk to them?
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Yes
Sometimes
Not yet
Does your baby chuckle softly?
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Yes
Sometimes
Not yet
After you have been out of sight, does your baby smile or get excited when they see you?
*
Yes
Sometimes
Not yet
Score For Communication Section
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Gross Motor
While your baby is on his back, does he wave his arms and legs, wiggle, and squirm?
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Yes
Sometimes
Not yet
When your baby is on their tummy, do they turn their head to the side?
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Yes
Sometimes
Not yet
When your baby is on their tummy, do they hold their head up longer than a few seconds?
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Yes
Sometimes
Not yet
When your baby is on their back, do they kick their legs?
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Yes
Sometimes
Not yet
While your baby is on their back, do they move their head from side to side?
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Yes
Sometimes
Not yet
After holding their head up while on their tummy, does your baby lay their head back down on the floor, rather than let it drop or fall forward?
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Yes
Sometimes
Not yet
Score For Gross Motor Section
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Fine Motor
Is your baby’s hand usually tightly closed when they are awake? (If your baby used to do this but no longer does, mark “yes.”)
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Yes
Sometimes
Not yet
Does your baby grasp your finger if you touch the palm of their hand?
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Yes
Sometimes
Not yet
When you put a toy in their hand, does your baby hold it in their hand briefly?
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Yes
Sometimes
Not yet
Does your baby touch their face with their hands?
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Yes
Sometimes
Not yet
Does your baby hold their hands open or partly open when they are awake (rather than in fists, as they were when they were a newborn)?
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Yes
Sometimes
Not yet
Does your baby grab or scratch at their clothes?
*
Yes
Sometimes
Not yet
Score for Fine Motor section
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Problem Solving
Does your baby look at objects that are 8–10 inches away?
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Yes
Sometimes
Not yet
When you move around, does your baby follow you with their eyes?
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Yes
Sometimes
Not yet
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 their eyes, sometimes turning their head?
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Yes
Sometimes
Not yet
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 their eyes?
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Yes
Sometimes
Not yet
When you hold your baby in a sitting position, do they look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of them?
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Yes
Sometimes
Not yet
When you dangle a toy above your baby while they lying on his back, do they wave their arms toward the toy?
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Yes
Sometimes
Not yet
Score for Problem Solving Section
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Personal-Social
Does your baby sometimes try to suck, even when they are not feeding?
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Yes
Sometimes
Not yet
Does your baby cry when they are hungry, wet, tired, or wants to be held?
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Yes
Sometimes
Not yet
Does your baby smile at you?
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Yes
Sometimes
Not yet
When you smile at your baby, do they smile back?
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Yes
Sometimes
Not yet
Does your baby watch their hands?
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Yes
Sometimes
Not yet
When your baby sees the breast or bottle, do they seem to know they're about to be fed?
*
Yes
Sometimes
Not yet
Score for Personal-Social section
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Overall
Did your baby pass the newborn hearing screening test? If no, explain:
If yes, leave blank. If no, explain.
Does your baby move both hands and both legs equally well? If no,explain:
If yes, leave blank. If no, explain.
Does either parent have a family history of childhood deafness, hearing impairment, or vision problems? If yes, explain:
If yes, leave blank. If no, explain.
Has your baby had any medical problems? If yes, explain:
If no, leave blank. If yes, explain.
Do you have concerns about your baby’s behavior (for example, eating, sleeping)? 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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