Ages & Stages Questionnaires®, Third Edition (ASQ®-3): 9 months
The following questions ask about activities children do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please check the box that tells whether your child is doing the activity regularly, sometimes, or not yet.Instructions:For some questions you will need small items, including a baby bottle, a book with pictures, Cheerios or other small food, cookies or crackers, a crib rail or other supportive furniture, a cup, paper, a string or shoelace, and a toy that is easy to grasp. Please have these items available before you start this questionnaire.Be sure to try each activity with your child before checking a box.Try to make completing this questionnaire a game that is fun for you and your child.Make sure your child is rested, fed, and ready to play.If you have any questions or concerns about your child or about this questionnaire, please call your doctor's office.ASQ®-3 © 2009 Brookes
Patient Name
First Name
Last Name
Patient DOB
-
Month
-
Day
Year
Date
Does your baby make sounds like "da," "ga," "ka," and "ba"?
*
Yes
Sometimes
Not yet
If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?
*
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.)
*
Yes
Sometimes
Not yet
If you ask your baby to, does he play at least one nursery game even if you don't show him the activity yourself (such as "bye-bye," "Peekaboo," "clap your hands," "So Big")?
*
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?
*
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.)
*
Yes
Sometimes
Not yet
If you hold both hands just to balance your baby, does she support her own weight while standing?
*
Yes
Sometimes
Not yet
When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?
*
Yes
Sometimes
Not yet
When you stand your baby next to furniture or the crib rail, does she hold on without leaning her chest against the furniture for support?
*
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?
*
Yes
Sometimes
Not yet
While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?
*
Yes
Sometimes
Not yet
Does your baby walk beside furniture while holding on with only one hand?
*
Yes
Sometimes
Not yet
Does your baby pick up a small toy with only one hand?
*
Yes
Sometimes
Not yet
Does your baby successfully pick up a crumb or Cheerio by using her thumb and all of her fingers in a raking motion? (If she already picks up a crumb or Cheerio, mark "yes" for this item.)
*
Yes
Sometimes
Not yet
Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)
*
Yes
Sometimes
Not yet
After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (The string may be attached to a toy.)
*
Yes
Sometimes
Not yet
Does your baby pick up a crumb or Cheerio with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it.
*
Yes
Sometimes
Not yet
Does your baby put a small toy down, without dropping it, and then take her hand off the toy?
*
Yes
Sometimes
Not yet
Does your baby pass a toy back and forth from one hand to the other?
*
Yes
Sometimes
Not yet
Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?
*
Yes
Sometimes
Not yet
When holding a toy in his hand, does your baby bang it against another toy on the table?
*
Yes
Sometimes
Not yet
While holding a small toy in each hand, does your baby clap the toys together (like "Pat-a-cake")?
*
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)?
*
Yes
Sometimes
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.)
*
Yes
Sometimes
Not yet
While your baby is on her back, does she put her foot in her mouth?
*
Yes
Sometimes
Not yet
Does your baby drink water, juice, or formula from a cup while you hold it?
*
Yes
Sometimes
Not yet
Does your baby feed himself a cracker or a cookie?
*
Yes
Sometimes
Not yet
When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn't let go of it? (If she already lets go of the toy into your hand, mark "yes" for this item.)
*
Yes
Sometimes
Not yet
When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?
*
Yes
Sometimes
Not yet
When you hold out your hand and ask for her toy, does your baby let go of it into your hand?
*
Yes
Sometimes
Not yet
Does your baby use both hands and both legs equally well?
*
Yes
No (Explain)
When you help your baby stand, are his feet flat on the surface most of the time?
*
Yes
No (Explain)
Do you have concerns that your baby is too quiet or does not make sounds like other babies?
*
No
Yes (Explain)
Does either parent have a family history of childhood deafness or hearing impairment?
*
No
Yes (Explain)
Do you have concerns about your baby's vision?
*
No
Yes (Explain)
Has your baby had any medical problems in the last several months?
*
No
Yes (Explain)
Do you have any concerns about your baby's behavior?
*
No
Yes (Explain)
Does anything about your baby worry you?
*
No
Yes (Explain)
Submit
Yes = 10, Sometimes = 5, Not Yet = 0
Communication Score - Cut Off 13.97
Gross Motor Score - Cut Off 17.82
Fine Motor Score - Cut Off 31.32
Problem Solving Score - Cut Off 28.72
Personal-Social Score - Cut Off 18.91
Should be Empty: