Ages & Stages Questionnaires®, Third Edition (ASQ®-3): 30 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
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
Without giving him 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. "Close the door." c. "Bring me a towel." d. "Find your coat." e. "Take my hand." f. "Get your book."
*
Yes
Sometimes
Not yet
When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does your child correctly point to at least seven body parts? (She can point to part of herself, you, or a doll. Mark "sometimes" if she correctly points to at least three different body parts.)
*
Yes
Sometimes
Not yet
Does your child make sentences that are three or four words long?
*
Yes
Sometimes
Not yet
Please give an example
Without giving your child help by pointing or using gestures, ask him to "put the book on the table" and "put the shoe under the chair." Does your child carry out both of these directions correctly?
*
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?"
*
Yes
Sometimes
Not yet
Does your child run fairly well, stopping herself without bumping into things or falling?
*
Yes
Sometimes
Not yet
Does your child walk either up or down at least two steps by himself? He may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)
*
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
Does your child jump with both feet leaving the floor at the same time?
*
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.) She may hold onto the railing or wall.
*
Yes
Sometimes
Not yet
Does your child stand on one foot for about 1 second without holding onto anything?
*
Yes
Sometimes
Not yet
Does your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?
*
Yes
Sometimes
Not yet
After your child watches you draw a line from 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?
*
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
After your child watches you draw a line from one side of the paper to the other side, ask her 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?
*
Yes
Sometimes
Not yet
After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle?
*
Yes
Sometimes
Not yet
Does your child turn pages in a book, one page at a time?
*
Yes
Sometimes
Not yet
When looking in the mirror, ask "Where is ___?" (Use your child's name.) Does your child point to her image in the mirror?
*
Yes
Sometimes
Not yet
If your child wants something he cannot reach, does he 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
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
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.")
*
Yes
Sometimes
Not yet
Please write your child's response here:
When you say, "Say 'seven three,'" does your child repeat just the two numbers in the correct 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.)
*
Yes
Sometimes
Not yet
After your child draws a "picture," even a simple scribble, does she tell you what she drew? (You may say, "Tell me about your picture," or ask, "What is this?" to prompt her.)
*
Yes
Sometimes
Not yet
If you do any of the following gestures, does your child copy at least one of them? a. Open and close your mouth b. Blink your eyes c. Pull on your earlobe d. Pat your cheek
*
Yes
Sometimes
Not yet
Does your child use a spoon to feed himself with little spilling?
*
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 she cannot turn?
*
Yes
Sometimes
Not yet
Does your child put on a coat, jacket, or shirt by himself?
*
Yes
Sometimes
Not yet
After you put on loose-fitting pants around her feet, does your child pull them completely up to her waist?
*
Yes
Sometimes
Not yet
When your child is looking in a mirror and you ask, "Who is in the mirror?" does he say either "me" or his own name?
*
Yes
Sometimes
Not yet
Do you think your child hears well?
*
Yes
No (Explain)
Do you think your child talks like other toddlers her age?
*
Yes
No (Explain)
Can you understand most of what your child says?
*
Yes
No (Explain)
Can other people understand most of what your child says?
*
Yes
No (Explain)
Do you think your child walks, runs, and climbs like other toddlers his age?
*
Yes
No (Explain)
Does either parent have a family history of childhood deafness or hearing impairment?
*
No
Yes (Explain)
Do you have concerns about your child's vision?
*
No
Yes (Explain)
Has your child had any medical problems in the last several months?
*
No
Yes (Explain)
Do you have any concerns about your child's behavior?
*
No
Yes (Explain)
Does anything about your child worry you?
*
No
Yes (Explain)
Submit
Yes = 10, Sometimes = 5, Not Yet = 0
Communication Score - Cut Off 33.30
Gross Motor Score - Cut Off 36.14
Fine Motor Score - Cut Off 19.25
Problem Solving Score - Cut Off 27.08
Personal-Social Score - Cut Off 32.01
Should be Empty: