ASQ 12 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 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 them the activity yourself (such as “bye-bye,” “Peeka-boo,” “clap your hands,” “So Big”)?
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Yes
Sometimes
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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Sometimes
Yes
Not yet
When you ask, “Where is the ball (hat, shoe, etc.)?” does your babylook at the object? (Make sure the object is present. Mark “yes” if theyknow one object.)
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Yes
Sometimes
Not yet
When your baby wants something, do they tell you by pointing to it?
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Yes
Sometimes
Not yet
Score For Communication Section
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Gross Motor
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
If you hold both hands just to balance your baby, do they take several steps without tripping or falling? (If your baby already walks alone, mark “yes” for this item.)
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Yes
Sometimes
Not yet
When you hold one hand just to balance your baby, do they take several steps forward? (If your baby already walks alone, mark “yes” for this item.)
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Yes
Sometimes
Not yet
Does your baby stand up in the middle of the floor by themself and take several steps forward?
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Yes
Sometimes
Not yet
Score For Gross Motor Section
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Fine Motor
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 orhand 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
Without resting their arm or hand on the table, does yourbaby pick up a crumb or Cheerio with the tips of theirthumb and a finger?
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Yes
Sometimes
Not yet
Does your baby throw a small ball with a forward arm motion? (If they simply drops the ball, mark “not yet” forthis item.)
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Yes
Sometimes
Not yet
Does your baby help turn the pages of a book? (You may lift a page forthem to grasp.)
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Yes
Sometimes
Not Yet
Score for Fine Motor section
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Problem Solving
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
If you put a small toy into a bowl or box, does your baby copy you byputting in a toy, although they may not let go of it? (If they already letgo of the toy into a bowl or box, mark “yes” for this item.)
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Yes
Sometimes
Not yet
Does your baby drop two small toys, one after theother, into a container like a bowl or box? (You mayshow him how to do it.)
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Yes
Sometimes
Not yet
After you scribble back and forth on paper with a crayon (or a pencil orpen), does your baby copy you by scribbling? (If they already scribbleson their own, mark “yes” for this item.)
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Yes
Sometimes
Not yet
Score for Problem Solving Section
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Personal-Social
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 thetoy 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
When you dress your baby, do they lift their foot for their shoe, sock, orpant leg?
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Yes
Sometimes
Not yet
Does your baby roll or throw a ball back to you so that you can return itto them?
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Yes
Sometimes
Not yet
Does your baby play with a doll or stuffed animal by hugging 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.
Does your baby play with sounds or seem to make words? If no, explain:
If yes, leave blank. If no, explain.
When you help your baby stand, are their feet flat on the surface mostof 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 hearingimpairment? 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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