| (&ASQ3) Ages & Stages | ) Questionnaires* { 23 ment 0 dys ough 25 moms 1 dos 4 Month Questionnaire 7 information Ute bck rue ony a ont 0 BH flr S [foley] ALLE f PROGRAM INFORMATION a OB Pal 101240100AASQ3 24 Month Questionnaire poe 7017 OVERALL owns 8 Doyou have any concerns about your child's behavior? If yes, explain: Gas Ow Shed polaron kde herage Se when she isin child [ke Seecings owes very quick be renct. She does'nt Nike sharing nel gets trast Vi she dlocant pickup a tAsK/cencept as quick ae she wovid liken 9. Does anything about your hid wor you? Hye, explin Os Ono Fay von'savetyindepaniens, and fbiwerrieel Seow with he’ being boo independent ancl getting hurt, physically dEmecrenally: She se head seed (never want that be play against her in any way. 101240700 108 SBeeain Bocas wonnog Co sangre’ASQ’ PROBLEM SOLVING ores 4 While your hid watches in up four cots ke ‘locks or cars arom, Does your ehld copy oF imitate you and ine up four abees in 8 ron? (Ou can also ute pools of thread, small boxes, or ‘other toys) PERSONAL-SOCIAL 1. Does your cil drink fom a cup or alos, putting it down again with le spiling? 2. Dees your child copy the actos you do, such a8 wipe uP a spill, ‘sneep, shove, of comb hai? 3. Does your child eat witha fork? 4 When playing with ether 2 stulfed animal ora dol, dows your cil pre tend 6 rock t, feed it change is dapers, putt to bed, and so forth? 5. Doce your child push alte wagon, soll, cr eter toy on whet, Soering ft sround objects and backing out of comers fhe cannot ten? {6 Does your child call herseif “or “me” more ofton than her own ‘ome? For example, “Ido it,” more often than "Juanita doi OVERALL Parents and providers may use the space below fr edltional comments 1. Do you think your chil hears wal? no, explain: 24 Month Questionnaire one So1? eo oo. oO ©. OR Ore *ERSONAL-SOCIAL TOTA ves Ono XN 2. Do you think your eh tals like other tors her age? no, exain | uh sure dOLS, | \ pede SUst WUD & £101240500 sor 8 gm concrete(AASQ3) 24 Month ASQ-3 information Summary 27" Cevnme Septem Allen Chids10 O days through 25 months 15 days — Date ASO completed UY 13, soa Abi 02 103/202 [ ewe minting program provide: — 1 SCORE AND TRANSFER TOTALS TO CHART rhe cle ase ee tES VO.SOMETIIES «5, NOTYET =O) Adon scce pe ef rea tot. ‘nSechartlon vane be ol cryin nthe ces cavemen ioe scores, $ sox i i mmo “wreom omnes Sr A03 Urs Gon hana g avons Yerewn OD) WO EN crern sme une as © ‘Comments: 2 2 ata er eddentaget ; Sonne @ ~ >» fy medial prelemst @® x ae omments: . oh % paerond ost nat yur st See i Commer Bw a Concerns sbout behavior? ae = oa Bw anton eb db a herd es see eens @ ©». ebeemama’ 2 vine cae Cimene el i so {Eee ig sien amu24 Month uestionnaire arse!” AASQ’ OVERALL wow? Se Ow amos of what your ene 57 72" cexplin 3. Can youunderstae Gnild has always been very advanced communicating my i ge? ae ims ke oor ta 4 Do you thine your cid was ns IF, exon 5 ener pen tng nay ca eats or ering peste? yes xP 4. po you he ag cone OU is don yes 02 srvyen ex Gs Ow 4 2 “poutine rt civey baa ecnemny aitren sty in ce, ) thma anal with Fig davgnter pee gRe ale Uns i s a ahem Maer | sre weather cons venely WE qaown, iv effets Mee pita hing. he has o eng prmme e en coiels 1012 ee aoe pga ReAASQ 24 Month Questionnaire poyeso!7 FINE MOTOR 1. Does your child get a spoon food usually does spi?” ° ° sai is mouth right side up so thatthe 2. Dota your child the pages bok by hs (She ay tn ° ‘more than one page ata time) ° ee 3. Does your child use a turing motion wth hishand while ying to turn doorknobs, wind up toys, twist tops, o screw ids on and of ars? 4 Does your chil fp switches off and on? AWA Aw 5, Does your child stack seven small blocks or tye ontop ofeach other bey heel? (ou could ako ure spool of tvead, small bates, or fys ‘that ae about finch in sie) fe} oO Oa 6 Ch youraiswang suelo alba, ‘een eroona Seog bet ome 0g Srihocuest rINE MO} ts souenes NOTE PROBLEM SOLVING fe} 1. Aterwateingyoucawatne om tesopotibe [RIN ° Go ane eaten sale cafer pdx roe Same your eh copy you by ang womgle tne on) ———_— Soper Ont taun S {hid srbblr bok and fot) ai 2. Altera crumb or Cheero is dropped into a small leer bottle, does SJour chi tur the bottle upside down to dump out the crumb or Greerio? (De not show him how) (You can use asoda-pop bottle or baby bottle) 3. Does you cild pretend objects are something ase? For example, does your child hold cup to er ear, pretending itis a telephone? [Does the put a box on her head, pretending it hat? Does she use a block or ell toy to sti food? 4. Does your child put things away where they belong? For example, does hhe know his toys belong onthe toy shlf his blanket goes on his bed, and dishes go inthe hitchen? kf 5, your child wants something she cannot reach, does she ind a chair o¢ ‘box to stand onto reach ft for example, to get a toy ona counter oF to “help” you nthe kitchen)? yf Sage Quran, Thr Eton AOI Sites Ber 101240400 100 8 Signal bose nuioiea Co alataAASQ 24 Month Questionnaire page 3et7 COMMUNICATION | cooses ves SOMETIMES. worver & Dossyourchdcomectyusesttamt wowodttemes tenes = GO ° your? MIMUNICATION TOTAL — GROSS MOTOR ves. SOMETIMES orver 1. Does your hid wak doom ssf youd onto one ote ands? SF oOo Oe ‘She may alo hold onto te rang or wal (You can Took for thi 3t “ore, on» playground, or at hme.) 2. Whenyoushow your cil how toca lage bal doeshe er o o — myer tetulymametsbytomeser vesting itl? if your ch oveach ks bal mak "ees for i this item ) a} iN | ib 3. Does your child walk ether up or down at least wo steps by hereof? She may hold ent the railing or wal 4. Does your ehild run fairly well, stopping herself without Dumping into things or fling? 4 Q ° ° | 5. Does your cil jump with both feet leaving the floor at the same time? Oo O° 16. Without holding onto anything for support, does your child ck 8 bal by swinging i leg formara? the ae & GROSS MOTOR TOTAL ‘Ages 4 Stages Quen, Tad Eton (S03 Sq E101240300 ‘CBaarPaan boat Rasahng Co Migs esd