a ASQ3) 18 Month Questionnaire rough 18 erator ‘On the following pages are questions about activities children may do, Your chill 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 n the circle that indicates whether your child is doing the activty regulary, sometimes, or not yet. Important Points to Remember: Notes: Try each activity with your chil before marking a response A Make completing this questionnaire a game that is fun for pleting this g 9 you and your child 1 Make sure your chit is rested and fe —____ A Please return this 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, ty the activities when your child is cooperative. If your child can do the activity but refuses, mark "yes" for the iter COMMUNICATION wes sowenwes —NoTyEr 1. When your child wants something, does she tell you by pointing toi? Oo oO oO 2. When you ask your child to, dows he go into another room to find a fax Oo oO oO miliar toy or abjecs? (You might ask, "Whereis your ball?” or say “Bring me your coat,” or “Go get your blanket.") 3. Does your child say eight or mare wards in adaition to “Mama” ane Oo Oo oO — "Dada"? 4. Does your child imitate a two-word sentance? For example, when you ° ° oOo — 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.) 5. Without your showing him, does your child point to the correct picture ° ° oO — wen you say, "Show me the kit" or ask, “Whereis the dog?” (He neds to identify only one picture correct) 6 Does your child say two or tree wards that represent cfferent ideas O ° Oo — together uch as "See dog,” “Mommy come home,” or "Kity gone"? (Cont count word combinations that express one idea, such as “bye bye," “al gone,” “all righ,” and “What's that?" Please give an ex- ample of your child's word combinations NX COMMUNICATION TOTAL = page 2016 [Ages & Stages Questionnsves, Third Edtion ASO), Saies & Becher 101180200 1 Sa00 Poul Brosces Pubtahing Ca. Allights reserveAASQ3) 418 Month Questionnaire pase s0r6 GROSS MOTOR es someTMes. «—_NOTYET Oo 1. Does your child bend over or squat to pick up an object from the floor ‘and then stand up again without any support? 2. Does your child move around by walking, rather than by crawling on her hands and knees? 3. Does your child walk well and seldom fall? oOo 0 0 oo 0 0 Oo oO 4. Does your child climb on an abject such asa chair to reach something Oo he wants (for example, to get a toy on a counter oF to “help” you Tn the kitchen)? 5. Does your child walk down stairs if you hold onto one of her hands? O° She may also hold onto the railing or wal. (You can look for ths at a store, on 2 playground, or at home) O Oo Oo Oo 6. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (if your child already kicks a ball, mark “yes” for this iter.) O° ° ° _ GROSS MOTORTOTAL = —__ FINE MOTOR ves SOMETIMES Nor ver 1. Does your child throw a small ball with a forward arm mation? (If he simply drops the ball, mark “not yet" for this {| item) mn 2. Does your child stack a small lock or toy ontop of another one? (You ° ° oO — could also use spools of thread, rmall boxes, toys that are about 1 inch in size) y O09 O09 OO = 3. Does your child make a matk on the paper with the tip Deere ima arr oe een Ss oO OO 4. Does your child stack three small blocks or toys on top of each other by Oo ° oO himself? 5. Does your child tum the pages of a book by himself?” (Me may turn O Oo o more than one page ata time) 6. Does your child get a spoon into her mouth right side up so thatthe O ° oOo — food usually doesn't spill? FINEMOTORTOTAL = __ [Ages & Stages Qustionnsives, Third Edltion ASO), Saies& Bicker 101180300 10 Ba09 Poul Brosces Publahing Ca. Allights eservesASQ3 18 Month Questionnaire pase 416 PROBLEM SOLVING 1 Does your child drop several small toys, one after another, nto a con- tainer ike a bowl or box? (You may show him how to do it) Oo ° O° — O° ° O — O° ° ° _ PROBLEM SOLVING TOTAL = —__. Solving Item & is marked sometimes,” mark Problem ‘Solving tem "yes O° O° — Oo Oo oO ° O° O° O ° ° oO _ PERSONAL-SOCIAL TOTAL = —_ 1), Squires & Bricker Se ee er re cho deseo ota et Tejcatinane seeseop bararsbejtoneh 5, Ae wae you eo re fom htop of ti Aneta on aa tee fommeret oN Fane te gore epenterpemtpm. St) N 6. tera cumb or Cheto i dtopped nts cla bate does PERSONAL-SOCIAL oper id tye ens 4. Bows our cit cove te you whan neds hl sch wih wining 5. oe your child inka up orl puting down asin wh weeping 6. oes yur sil ony th act you do, sch a wna vo ererie0s20 serps Rede ea Sa(&ASQ3) 18 Month Questionnaire page 5016 OVERALL Parents and providers may use the space below for additional comments, 1. Do you thine your child hears well? Ino, explain: Ons Ono 2. Do you thnk your chill tas ke other toler his age? Ino, explain Ows Ono 3. Can you understand most of what your child says? If no, explain: Oxs Ono 4. Do you think your hil walks, uns, and climbs lke other todlers her age? Ows Ono Ina, explain: 5. Does either parent have a family history of childhood deafness or hearing Ove Ono impairment? If yes, explain 6 Do you have concerns about your chills sion? Ifyes, explain Ous Ono Ages & Stage: Questonnaves®, Third Edtion A503"), Squces& Bicker 101180500 162009 Pau Bross Publshing Co. Alright reseneASQ3) 418 Month Questionnaire pose 6016 OVERALL Gensinues) 7. Has your eld had any medical problems inthe last several months yes, expan Ow Ono XN 8. Do you have any concerns about your child's behavior? If yes, explain Ove Ono 9. Does anything about your child worry you? If yes, explain: Ons Ono Ages & Stage: Questonnaves®, Third Edtion A503"), Squces& Bicker 101180600 10 Sa00 Poul Brosces Pushing Ca. Allights eserves(&ASQ3) Child's name: Child's 10 #: Administering program/provider 17 months 0 days through 18 Month ASQ-3 Information Summary 18 monte 30 dae Date ASQ complet Date of birch Was age adjusted for prematurity when selecting questionnaire? Oves One 1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASO-3 User's Guide for details, including how to adjust scores ifitem responses are missing. Score each item (YES 10, SOMETIMES = 5, NOT YET = 0). Add itern scores, and record each area total. In the chart below, transfer the total scores, and ill in the circles corresponding with the total scores. ars [curt | Fae | os 1015205305 Commanicnion | 13.06 Gross Mover [37.38 Fire Mover [3432 Freblem Sehing | 25.74 Peronatsocat [27.19 2, TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6 1. Hears well? Comments: 2. Talks like other toddlers his age? Comments: 3. Understand most of what your chile says? Comments: 4. Walks, runs, and climbs like other toddlers? Comments: 5. Family history of hearing impairment? ‘Commen Yes NO 6 Concerns about vision? YES No Comments: Yes NO 7. Any medical problems? YES No Comments: Yes NO 8 Concerns about behavior? YES No Comments: Yes NO 9 Other concerns? YES No Comments: YES No 3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall responses, and other considerations, such a8 opportunities to practice skils, to determine aporopriate follow-up, If the child's total score isin the 1 area, If the child's total score isin the [EI area, is above the cutoff, and the child's development appears to be on schedule. is close to the cutoff. Provide learning activities and monitor. the child's total score isin the lll area, itis below the cutoff, Further assessment with a professional may be needed. 4, FOLLOW-UP ACTION TAKEN: Check all that apply. Provide activities and rescreen in reason): Share results with primary health care provider. Refer for {circle all that apply) hearing, vision, and/or behavioral screening Refer to primary health care provider or other community agency (specify 5. OPTIONAL: Transfer item responses {Y= YES, § = SOMETIMES, N = NOT YET, montis: X = response missing). 1[2]3]4[5]6 No further action taken at this time Other (specify) Refer to early intervention/early childhood special education om Solving Persona Socal ‘Ages & Stags Questionnsies®, Third Edin (AS0-2™),Sauies& richer P101180700 1 Sa00 Poul Brosces Publahing Ca. Align eseree