ASQ 9 months
Child's Name
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First Name
Last Name
Parent/Guardian filling out form
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First Name
Last Name
Email
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example@example.com
Child's Birthday
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/
Month
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Day
Year
Date
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Communication Section
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
Does your baby make two similar sounds like “ba-ba,” “da-da,” or“ga-ga”? (The sounds do not need to mean anything.)
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Yes
Sometimes
Not yet
If you ask your baby to, do they play at least one nursery game even if you don’t show her the activity yourself (such as “bye-bye,” “Peeka-boo,” “clap your hands,” “So Big”)?
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Sometimes
Yes
Not yet
Does your baby follow one simple command, such as “Come here,”“Give it to me,” or “Put it back,” without your using gestures?
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Yes
Sometimes
Not yet
Does your baby say three words, such as “Mama,” “Dada,” and“Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)
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Yes
Sometimes
Not yet
Score For Communication Section
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Gross Motor
If you hold both hands just to balance your baby, do they support her own weight while standing?
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Yes
Sometimes
Not yet
When sitting on the floor, does your baby sit up straight for several minutes without using their hands for support?
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Yes
Sometimes
Not yet
When you stand your baby next to furniture or the crib rail, do they hold on without leaning their chest against the furniture for support?
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Yes
Sometimes
Not yet
While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?
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Yes
Sometimes
Not yet
While holding onto furniture, does your baby lower themself with control (without falling or flopping down)?
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Yes
Sometimes
Not yet
Does your baby walk beside furniture while holding on with only one hand?
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Yes
Sometimes
Not yet
Score For Gross Motor Section
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Fine Motor
Does your baby pick up a small toy with only one hand?
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Yes
Sometimes
Not yet
Does your baby successfully pick up a crumb or Cheerio by using their thumb and all of their fingers in a raking motion? (If they already picks up a 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 the tips of their thumb and fingers? (You should see a space between the toy and his palm.)
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Yes
Sometimes
Not yet
After one or two tries, does your baby pick up a piece of string with their first finger and thumb? (The string may be attached to a toy.)
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Yes
Sometimes
Not yet
Does your baby pick up a crumb or Cheerio with the tips of their thumb and a finger? They may rest their arm or hand on the table while doing it.
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Yes
Sometimes
Not yet
Does your baby put a small toy down, without dropping it, and then take their hand off the toy?
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Yes
Sometimes
Not yet
Score for Fine Motor section
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Problem Solving
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 pick up two small toys, one in each hand, and hold onto them for about 1 minute?
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Yes
Sometimes
Not yet
When holding a toy in their hand, does your baby bang it against another toy on the table?
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Yes
Sometimes
Not yet
While holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?
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Yes
Sometimes
Not yet
Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?
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Yes
Not yet
After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.)
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Yes
Sometimes
Not yet
Score for Problem Solving Section
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Personal-Social
While your baby is on their back, do they put their foot in her mouth?
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Yes
Sometimes
Not yet
Does your baby drink water, juice, or formula from a cup while you hold it?
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Yes
Sometimes
Not yet
Does your baby feed themself a cracker or a cookie?
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Yes
Sometimes
Not yet
When you hold out your hand and ask for their toy, does your baby offer it to you even if they don't let go of it? (If they already let go of the toy into your hand, mark “yes” for this item.)
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Yes
Sometimes
Not yet
When you dress your baby, do they push their arm through a sleeve once their arm is started in the hole of the sleeve?
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Yes
Sometimes
Not yet
When you hold out your hand and ask for their toy, does your baby let go of it into your hand?
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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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