60 Month Questionnaire

  • 60 Month Questionnaire

    Please provide the following information
  • Date ASQ completed:
     - -

  • Child's Information

  • Child's date of birth:
     - -
  • Child's gender:

  • Person filling out questionnaire

  • Relation to child:
  •  -
  •  -

  • Program Information

  • On the following pages are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not began doing yet. For each item please select that indicates whether your child is doing the activity regularly, sometimes, not yet.

    Important Points to Remember:

    • Try each activity with your child before marking a response.
    • Make completing this questionnaire a game that is fun for you and your child.
    • Make sure your child is rested and fed.

  • COMMUNICATION

  • 1. Without your giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down," or "Give me the pen, open the book, and stand up."
  • 2. Does your child use four- and five-word sentences? For example, does your child say, "l want the car"?
  • 3. When talking about something that already happened, does your child use words that end in "-ed," such as "walked" "jumped," or "played"? Ask your child questions, such as "How did you get to the store?" ("We walked. "What did you do at your friend's house?" ("We played.")
  • 4. Does your child use comparison words, such as "heavier," "stronger," or "shorter"? Ask your child questions, such as "A car is big, but a bus (bigger); "A cat is heavy, but a man is (heavier); "A TV is small, but a book is " (smaller).
  • 5. Does your child answer the following questions? (Mark "sometimes" if your child answers only one question.)
  • 6. Does your child repeat the sentences shown below back to you, without any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark "yes" if your child repeats both sentences without mistakes or "sometimes" if your child repeats one sentence without mistakes.)

  • GROSS MOTOR

  • 1. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as "not yet. ")
  • 2. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)
  • 3. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)
  • 4. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)
  • 5. Does your child hop forward On one foot for a distance of 4—6 feet without putting down the other foot? (You may give her two tries on each foot. Mark "sometimes" if she can hop on one foot only.)
  • 6. Does your child skip using alternating feet? (You may show him how to do this.)

  • FINE MOTOR

  • 1. Ask your child to trace on the line below with a pencil. Does your child trace on the line without going off the line more than two times? (Mark "sometimes" if your child goes off the line three times.)
  • 2. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, "Draw a picture of a girl or a boy." If your child draws a person with head, body, arms, and legs, mark "yes." If your child draws a person with only three parts (head, body, arms, or legs), mark "sometimes." If your child draws a person with two or fewer parts (head, body, arms, or legs), mark "not yet." Be sure to include the sheet of paper with your child's drawing with this questionnaire.
  • 3. Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child's use of scissors for safety reasons.)
  • 4. Using the shapes below to look at, does your child copy the shapes in the space below without tracing? (Your child's drawings should look similar to the design of the shapes below, but they may be different in size. Mark "yes" if she copies all three shapes; mark "sometimes" if your child copies two shapes.)

  • 5. Using the letters below to look at, does your child copy the letters without tracing? Cover up all of the letters except the letter being copied. (Mark "yes" if your child copies four of the letters and you Can read them. Mark "sometimes" if your child copies two or three letters and you can read them.)

  • 6. Print your child's first name. Can your child copy the letters? The letters may be large, backward, or reversed. (Mark "sometimes" if your child copies about half of the letters.)

  • PROBLEM SOLVING

  • 1. When asked, "Which circle is smallest?" does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)

  • 2. When shown objects and asked, "What color is this?" does your child name five different colors like red, blue, yellow, orange, black, white, or pink? (Mark "yes" only if your child answers the question correctly using five colors.)
  • 3. Does your child count up to 15 without making mistakes? If so, mark "yes." If your child counts to 12 without making mistakes, mark "sometimes."
  • 4. Does your child finish the following Sentences using a word that means the opposite of the word that is italicized? For example: MA rock is hard, and a pillow is soft." (Mark "yes" if he finishes three off our sentences correctly. Mark "sometimes" if he finishes two off our sentences correctly.)
  • 5. Does your child know the names of numbers? (Mark "yes" if she identifies the three numbers below. Mark "sometimes" if she identifies two numbers.)

  • 6. Does your child name at least four letters in her name? Point to the letters and ask, "What letter is this?" (Point to the letters out of order,)

  • PERSONAL SOCIAL

  • 1. Can your child serve himself. taking food from one container to another, using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?
  • 2. Does your child wash her hands and face using soap and water and dry off with a towel without help?
  • 3. Does your child tell you at least four of the following?
  • Please mark the items your child knows.
  • 4. Does your child dress and undress himself, including buttoning medium-size buttons and zipping front zippers?
  • 5. Does your child use the toilet by herself? (She goes to the bathroom, sits on the toilet, wipes, and flushes.) Mark "yes" even if she does this after you remind her.
  • 6. Does your child usually take turns and share with other children?

  • OVERALL

    Parents and providers may use the space below for additional comments.
  • 1. Do you think your child hears well?
  • 2. Do you think your child talks like other children her age?
  • 3. Can you understand most of what your child says?
  • 4. Can other people understand most of what your child says?
  • 5. Do you think your child walks, runs and climbs like other children his age?
  • 6. Does either parent have a family history of childhood deafness or hearing impairment?
  • 7. Do you have concerns about your child's vision?
  • 8. Has your child had any medical problems in the last several months?
  • 9. Do you have any concerns about your child's behavior?
  • 10. Does anything about your child worry you?
  • Should be Empty: