ASQ 24 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
Back
Next
Communication Section
Without your showing them, does your child point to the correct picture when you say, “Show me the kitty,” or ask, “Where is the dog?” (They need to identify only one picture correctly.)
*
Yes
Sometimes
Not yet
Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as “Mama eat,” “Daddy play,” “Go home,” or “What’s this?” does your child say both words back to you? (Mark “yes” even if their words are difficult to understand.)
*
Yes
Sometimes
Not yet
Without your giving them clues by pointing or using gestures, can your child carry out at least three of these kinds of directions? (a. “Put the toy on the table.” b. “Find your coat.” c. “Close the door.” d. “Take my hand.” e. “Bring me a towel.” f. “Get your book.”)
*
Yes
Sometimes
Not yet
If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child,“What is this?” does your child correctly name at least one picture?
*
Yes
Sometimes
Not yet
Does your child correctly use at least two words like “me,” “I,” “mine,”and “you”?
*
Yes
Sometimes
Not yet
Does your child say two or three words that represent different ideas together, such as “See dog,” “Mommy come home,” or “Kitty gone”? (Don’t count word combinations that express one idea, such as “bye-bye,” “all gone,” “all right,” and “What’s that?”)
*
Yes
Sometimes
Not yet
Score For Communication Section
Back
Next
Gross Motor
Does your child walk down stairs if you hold onto one of their hands? They may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
*
Yes
Sometimes
Not yet
When you show your child how to kick a large ball, do they try to kick the ball by moving their leg forward or by walking in to it? (If your child already kicks a ball, mark “yes” for this item.)
*
Yes
Sometimes
Not yet
Does your child walk either up or down at least two steps by themself? They may hold onto the railing or wall.
*
Yes
Sometimes
Not yet
Does your child run fairly well, stopping themself without bumping into things or falling?
*
Yes
Sometimes
Not yet
Does your child jump with both feet leaving the floor at the same time?
*
Yes
Sometimes
Not yet
Without holding onto anything for support, does your child kick a ball by swinging his leg forward?
*
Yes
Sometimes
Not yet
Score For Gross Motor Section
Back
Next
Fine Motor
Does your child get a spoon into their mouth right side up so that the food usually doesn’t spill?
*
Yes
Sometimes
Not yet
Does your child turn the pages of a book by themself? (They may turn more than one page at a time.)
*
Yes
Sometimes
Not yet
Does your child stack seven small blocks or toys on top of each other by themself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)
*
Yes
Sometimes
Not yet
Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?
*
Yes
Sometimes
Not yet
Does your child flip switches off and on?
*
Yes
Sometimes
Not yet
Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?
*
Yes
Sometimes
Not yet
Score for Fine Motor section
Back
Next
Problem Solving
Does your child pretend objects are something else? For example, does your child hold a cup to their ear, pretending it is a telephone? Do they put a box on their head, pretending it is a hat? Do they use a block or small toy to stir food?
*
Yes
Sometimes
Not yet
Does your child put things away where they belong? For example, do they know their toys belong on the toy shelf, their blanket goes on their bed, and dishes go in the kitchen?
*
Yes
Sometimes
Not yet
After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle over to dump it out? (You may show them how.) (You can use a soda pop bottle or a baby bottle.)
*
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)?
*
Yes
Sometimes
Not yet
After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark “not yet” if your child scribbles back and forth.)
*
Yes
Sometimes
Not yet
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.)
*
Yes
Sometimes
Not yet
Score for Problem Solving Section
Back
Next
Personal-Social
Does your child drink from a cup or glass, putting it down again with little spilling?
*
Yes
Sometimes
Not yet
Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?
*
Yes
Sometimes
Not yet
Does your child eat with a fork?
*
Yes
Sometimes
Not yet
When playing with either a stuffed animal or a doll, does your child pretend to rock it, feed it, change its diapers, put it to bed, and so forth?
*
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?
*
Yes
Sometimes
Not yet
Does your child call herself “I” or “me” more often than her own name? For example, “I do it,” more often than “Juanita do it.”
*
Yes
Sometimes
Not yet
Score for Personal-Social section
Back
Next
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.
Does either parent have a family history of childhood deafness or hearing impairment?
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 baby had any medical problems in the last several months?
If no, leave blank. If yes, explain.
Do you have any concerns about your baby’s behavior?
If no, leave blank. If yes, explain.
Does anything about your baby worry you?
If no, leave blank. If yes, explain.
Submit
Should be Empty: