ASC 3 Ages & Stages Questionnaires® 23 months Oday ough 2 months 15 dos 24 Month Questionnaire Please provide th flowing infomation Use lk or Bl in oly and pnt Igy hen ampletng for Date ASO completed: wMDOVY YY Child's information ide chide fstrame MEE cht nt nae chads dt oft chi oender O mao O Female wwopYY YY Person filling out questionnaire = We Soeetaddeee Rentorship teil O tater © Sider Cotter ow erro code coun Home leone number ter lphon number Emaar Names of people asistngn questionnie completion: PROGRAM INFORMATION Chis cs & Stages Qetonnsis®, Th Edon (ASO3™), Squires B Bicker 101240100 foes 8 BaP Sone Punahing Go Al re sare24 Month Questionnaire any iinet A&ASQ (On the following pages are questions about actvities children may 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 fil in the circle that indicates whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: Notes: Ty each acy with your chill before making a response Make completing this questionnaire a game thats fun for you and your child A Make sure your child is rested and fed. 4 Please etum ths questionnaire by At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your child more than one time. If possible, ‘ry the activities when your child is cooperative. if your child can do the activity but refuses, mark “yes” for the item. COMMUNICATION ws somenmes —Norver 1. Without your showing him, does your child point tothe correct picture Oo oO oO ~— when you say, "Show me the kitty,” or ask, "Where is the dag?” (She needs to identify only one picture correctly) 2. Does your child imitate a two-word sentence? For example, when you Oo o ~— 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 her words are dificult to understand.) 3. Without your giving him clues by pointing or using gestures, can your O O oO ~— child cary out at least three ofthese kinds of directions? © a."Putthe toy on the table." ©) d.*Find your coat.” O b."Close the door” © e."Take my hand.” O "Bring me a towel.” O £.*Get your book 4. you point to a picture of a bal (ity, cup, hat, etc) and ask your child, oO ° oO — What is this?” does your child correctly name atleast one picture? 5. Does your child say two or three words that represent different ideas oO ° oe together, such as "See dog," “Mommy come home," or "Kitty gone"? (Don't count word combinations that express one idee, such as “bye- bye,” “all gone,” “alright,” and "What's that?") Please give an ex ample of your child's word combinations: Va / age 2047 ‘Aer & Snges Gueronnivs®, Th Edion (ASO3™, Squires B Bicker 101240200 {Baap toaH SrockarPulahing Go. Alig vsoved(ASQ) 24 Month Questionnaire page 30f7 COMMUNICATION | covinect ws somermes—-Norve 6. Does your child correctly use at least two words like “me,” "" “mine,” Oo °O ° and "you"? COMMUNICATION TOTAL GROSS MOTOR ves SOMETINES Norver 1. Does your child walk down stats you hold onto one of her hands? Oo Oo Oo 2, 3 4 5. 6 She may alzo hold onto the railing or wall. (You can look for this at @ store, on a playground, or at home.) When you show your child how to kick a large ball, does he tty to kick the ball by moving his leg forward or by walking into it? (Ifyour child already kicks @ ball, mark "yes" for this item.) ° oO Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wal Does your child run fairly well, stopping herself without ‘bumping into things or falling? 2 Does your chi jum with both fet leaving the floor athe S52 Oo oO same time? # Without holding onto anything for support, dees your child kick a ball by swinging his leg forward? ° ° Gross Mos ‘Ager & Stages Questionnies9, This Eton (ASO. 3), Sguies & Bricker, 101240300 {© 2o0y Pau H Sroske Pushing Ca Alloghts reserved ross Motor O° Oo Oo GROSS MOTOR TOTAL Item 6 is marked sometimes,” mark them 2 “yes.AASQ3) 24 Month Questionnaire page 4017 FINE MOTOR ws somermes—-Norve 1. Does your child get a spoon into his mouth right side up so that the Oo Oo oOo — food usually doesn’t spil? 2. Does your child turn the pages of a book by hersel? (She may tun oO O o — more than one page ata time.) 3. Does your child use a turning motion with his hand while trying to turn oO ° oO — doorknobs, wind Up toys, twist tops, or screw lds on and off jas? 4. Does your child fp switches off and on? oO ° on 5. Does your child stack seven small blocks or toys on top of each other oO ° on by herself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size) ° ° ° | ‘macaroni, or pasta “wagon wheels” onto a string oF shoelace? FINE MOTOR TOTAL = __ PROBLEM SOLVING ves mes NoTYE coun aye" 1. After watching you draw a line from the top of the Wn Oo O oO — 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" fyour Courter child scribbles back and forth) - CI 2. After a crumb or Cheerios dropped into a small, clear bottle, dows Oo ° oOo — your child turn the bottle upside down to dump our the crumb or Cheerio? (Do not show him how.) (You can use a sode-pop bottle or baby bottle) 3. Does your child pretend objects are something else? For example, Oo O° oOo — does your child hold a cup to her ear, pretending iis a telephone? Does she put a box on her head, pretending itis a hat? Ooes she use a block or small toy to sti food? 44. Does your child put things away where they belong? For example, does Oo ° oO he know his toys belong on the toy self, his blanket goes on his bed, and cishes go inthe kitchen? 5. If your child wants something she cannot reach, does she find chair or O O o ~— box to stand on to reach it (for example, to get a toy on a counter orto “help” you in the kitchen]? ‘Aer & Snges Gueronnivs®, Th Edion (ASO3™, Squires B Bicker 101240400 {Baap toaH SrockarPulahing Go. Alig vsoved(RASQ3) 24 Month Questionnaire page 5of7 PROBLEM SOLVING cenines) ves. SOMETIMES Noryer Oo Oo oO — 6 While your child watches, line up four objects like blocks oF cars in a row. Does your child copy or imitate you and line up four objects in 2 row? (You ‘can also use spools of thread, small boxes, or other toys.) PROBLEM SOLVING TOTAL = __. PERSONAL-SOCIAL ves, SOMETIMES Notver Oo oO — 1. Does your child drink from a cup or glass, putting it down again with little spilling? 2. Does your child copy the activities you do, such as wipe up a spil sweep, shave, or comb hair? 3, Does your child eat with a fork? 4, When playing with either a stuffed animal or a doll, does your child pre- tend to rockit, feed it, change its diapers, put itto bed, and so forth? Oo 00 0 Oo 00 0 5. Does your child push a litle wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners ifhe cannot turn? oo0o00 0 0 6. Doss your child call herself I" or “me” more often than her own name? For example, "| do it,” more often than "Juanita do it.” ° ° | PERSONAL-SOCIAL TOTAL = —__ OVERALL Parents and providers may use the space below for additional comments 1. Do you think your child hears well? if no, explain: Ow Ono 2. Doyou think your child talks like other toddlers her age? Ino, explain: Ons Ono cs & Stages Qetonnsis®, Th Edon (ASO3™), Squires B Bicker 101240500 foes 8 BaP Sone Punahing Go Al re sare(RASQ3) 24 Month Questionnaire page 60f7 OVERALL coninves) 3. Can you understand most of what your child says? Ifno, explain: Ons Ono 4, Do you think your child walks, runs, and climbs like other toddlers his age? Ow Ono If no, explain: 5. Does either parent have a family history of childhood deafness or hearing Ors Ono impairment? If yes, explain: 6 Doyouhave any concerns about your child's vision? If yes, explain Ons Ono 7. Has your child had any medical problems in the last several months? if yes, explain: Ow Ono cs & Stages Qetonnsis®, Th Edon (ASO3™), Squires B Bicker 101240600 foes 8 BaP Sone Punahing Go Al re sare(BASQ3) 24 Month Questionnaire poe 7017 OVERALL ( coninves) 8. Do you have any concerns about your child's behavior? If yes, explain Ors Ono 9. Does anything about your child worry you? If yes, explain: Ow Ono cs & Stages Qetonnsis®, Th Edon (ASO3™), Squires B Bicker 101240700 foes 8 BaP Sone Punahing Go Al re sare(&ASQ3) Child's name: Child's 1 # Date of birth Administering program/provider: 1 2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6, 1. Hears well? Yes NO 6. Concerns about vision? Yes Comments: Comments 2. Talks lke other toddlers his age? Yes NO 7. Anymedical problems? Yes Comments: ‘Comments 3. Understand most of what your child says? Yes NO 8. Concerns about behavior? Yes Comments Comments 4. Walks, runs, and climbs ike other toddlers? Yes. «NO 9. Other concerns? Yes Comments Comments 5. Family history of hearing impaitment? YES No Comments: 3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall responses, and other considerations, such as opportunites to practice skills, to determine appropriate follow-up. if the chile’s total score is in the [=] area itis above the cutoff, and the child's development appears to be on schedule. W the child's total score is in the EI area, ii close to the cutoff Provide learning activities and monitor. If the chile’ total score is in the Ill area, itis below the cutoff. Further assessment with a professional may be needed 4, FOLLOW-UP ACTION TAKEN: Check al that apply 5. OPTIONAL: Transfer item responses (Y= YES, § = SOMETIMES, N= NOT YET, Provide activites and rescreen in_months. X = response missing) Share results with primary health care provider. Prmany , ‘P2[a/4 Refer for (circle all that apply) hearing, vision, and/or behavioral screening = 7 Refer to primary health care provider or other community agency (specify es reason Refer to early intervention/early childhood special education rector Problem Soking No further action taken at this time Personal Socal Other (specify: ‘Ages & Stages Questonnsies®, Tid Ein ASO.I™), Suites & Bricker P101240800 tet Woos Pall Sooke Publehing Co Al ghana. 24 Month ASQ-3 Information Summary Date ASQ completed: 23 months O days through 25 months 15 days ‘SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASO-3 User's Guide for detail, including how to adjust scores ifitem 0, SOMETIME: responses are missing. Score each item (YE |, NOT YET In the chart below, transfer the total scores, and filin the circles corresponding with the total scores. ares | cast | Sow | O05 1015 202530 3540 45 0}. Add item scores, and record each area total Conmanicnion [25.17 Oo Gro Mater | 38.07 Problem Sabing [29.78 Penonaiseca! [31.54 O10 oO oO Oo oO oO IOjO O lO|O|O/OJO}s oO lO|O|O|OJO}# lO|OjOJojols No No