ASQ 3 years
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Last Name
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First Name
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example@example.com
Child's Birthday
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Communication Section
When you ask your child to point to their nose, eyes, hair, feet, ears, and so forth, do they correctly point to at least seven body parts? (They can point to parts of themself, you, or a doll. Mark “sometimes” if they correctly point to at least three different body parts.)
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Yes
Sometimes
Not yet
Show your child how a zipper on a coat moves up and down, and say, “See, this goes up and down.” Put the zipper to the middle and ask your child to move the zipper down. Return the zipper to the middle and ask your child to move the zipper up. Do this several times, placing the zipper in the middle before asking your child to move it up or down. Does your child consistently move the zipper up when you say “up” and down when you say “down”?
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Yes
Sometimes
Not yet
When you ask, “What is your name?” does your child say both their first and last names?
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Yes
Sometimes
Not yet
Does your child make sentences that are three or four words long?
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Yes
Sometimes
Not yet
Please give an example:
Without giving your child help by pointing or using gestures, ask them to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly?
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Yes
Sometimes
Not yet
When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, “barking,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?”
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Yes
Sometimes
Not yet
Score For Communication Section
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Gross Motor
Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
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Yes
Sometimes
Not yet
Does your child jump with both feet leaving the floor at the same time?
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Yes
Sometimes
Not yet
Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) They may hold onto the railing or wall.
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Yes
Sometimes
Not yet
Does your child stand on one foot for about 1 second without holding onto anything?
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Yes
Sometimes
Not yet
While standing, does your child throw a ball overhand by raising their arm to shoulder height and throwing the ball forward? (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)
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Yes
Sometimes
Not yet
Does your child jump forward at least 6 inches with both feet leaving the ground at the same time?
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Yes
Sometimes
Not yet
Score For Gross Motor Section
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Fine Motor
After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction?
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Yes
Sometimes
Not yet
Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
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Yes
Sometimes
Not yet
After your child watches you draw a single circle, ask them to make a circle like yours. Do not let them trace your circle. Does your child copy you by drawing a circle?
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Yes
Sometimes
Not yet
After your child watches you draw a line from one side of the paper to the other side, ask them to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction?
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Yes
Sometimes
Not yet
Does your child try to cut paper with child-safe scissors? They do not need to cut the paper but must get the blades to open and close while holding the paper with the other hand. (You may show your child how to use scissors. Carefully watch your child’s use of scissors for safety reasons.)
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Yes
Sometimes
Not yet
When drawing, does your child hold a pencil, crayon, or pen between their fingers and thumb like an adult does?
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Yes
Sometimes
Not yet
Score for Fine Motor section
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Problem Solving
While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes, or other toys.)
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Yes
Sometimes
Not yet
If your child wants something they cannot reach, do they find a chair or box to stand on to reach it (for example, to get a toy on a counter or to“help” you in the kitchen)?
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Yes
Sometimes
Not yet
When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,”“boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”) Please write your child’s response here:
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Yes
Sometimes
Not yet
When you say, “Say ‘seven three,’” does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, “Say ‘eight two.’” Your child must repeat just one series of two numbers for you to answer “yes” to this question.
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Yes
Sometimes
Not yet
Show your child how to make a bridge with blocks, boxes, or cans, like the example. Does your child copy you by making one like it?
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Yes
Sometimes
Not yet
When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers for you to answer “yes” to this question.)
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Yes
Sometimes
Not yet
Score for Problem Solving Section
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Personal-Social
Does your child use a spoon to feed himself with little spilling?
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Yes
Sometimes
Not yet
Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if they cannot turn?
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Yes
Sometimes
Not yet
When your child is looking in a mirror and you ask, “Who is in the mirror?” do they say either “me” or their own name?
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Yes
Sometimes
Not yet
Using these exact words, ask your child, “Are you a girl or a boy?” Does your child answer correctly?
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Yes
Sometimes
Not yet
Does your child put on a coat, jacket, or shirt by themself?
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Yes
Sometimes
Not yet
Does your child take turns by waiting while another child or adult takes a turn?
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Yes
Sometimes
Not yet
Score for Personal-Social section
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Overall
Do you think your child hears well?
If yes, leave blank. If no, explain.
Do you think your child talks like other toddlers their age?
If yes, leave blank. If no, explain.
Do you think your child walks, runs, and climbs like other toddlers their age? If no, explain:
If yes, leave blank. If no, explain.
Can you understand most of what your child says?
If yes, leave blank. If no, explain.
Can other people understand most of what your child says? If no, explain:
If no, leave blank. If yes, explain.
Do you have concerns about your child’s vision?
If no, leave blank. If yes, explain.
Has your child had any medical problems in the last several months?
If no, leave blank. If yes, explain.
Do you have any concerns about your child's behavior?
If no, leave blank. If yes, explain.
Does anything about your child worry you?
If no, leave blank. If yes, explain.
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