(8 ASQ3) J Month Questionnaire syough ers On the following pages are questions about activities babies may do, Your baby may have already done some of the activities described here, and there may be some your baby has not bequn doing yet. For each iter, please fil in the circle that indi- ceates whether your baby is doing the activity regularly, sometimes, or not yet. Important Points to Remember: Notes: & Tay each activity with your baby before marking a response 1 Make completing this questionnaire a game thats fun for you ard your baby Make sure your baby is rested andl fod —____ A Please return this questionnaire by. COMMUNICATION ¥ 1. Does your baby make sounds ike “da,” "ga," "ka,” and "ba"? SoMEMMES ——_-NOTYET O °O oo 2. you copy the sounds your baby makes, does your baby repeat the same sounds back to you? dada,” or Oo 0° O° Oo 3, Does your baby make two similar sounds like "ba-b "ga-ga"? (The sounds do not need to mean anything.) 4. tfyou ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself such as “bye-bye,” boo,” “clap your hands,” "Se Big’)? oO Oo Oo Oo — oO °O O° — 5. Does your baby follow one simple command, such as "Come here,” ‘Give it to me,” or “Put it back," without your using gestures? 6. Does your baby say three words, such as “Mama,” “Dada,” and Oo Oo oOo — Baba"? (A "word" isa sound or sounds your baby says consistently t0 mean someane or something.) COMMUNICATION TOTAL = GROSS MOTOR ves SOMETIMES Notver 9 °O O° — 1. Ifyou hold both hands just to balance your baby, does she support her own weight while standing? 3 2. When sitting onthe floor, does your baby st up straight for oF oO Oo o ~— several minutes without using his hands for support? is page 2016 [Ages & Stages Questionnsves, Third Edtion ASO), Saies & Becher 101090201 1 Sa00 Poul Brosces Pubtahing Ca. Allights reserveAASQ3 9 Month Questionnaire page 30F6 GROSS MOTOR ccninusa) ves SOMETIMES Norver 2. When you stand your baby next to furniture or the ci ral, does she hold on without leaning her chest against the furniture for support? O° Oo Oo —_— 4. While holding onto furniture, does your baby bend down ‘and pick up a toy from the floor and then return to 3 standing position? 5. While holding onto furniture, does your baby lower himself with control oO O° oO = (without falling ar flapping down)? 6. Does your baby walk beside furniture while holding on with only one: ) Oo oO. hand? GROSS MOTOR TOTAL = __ FINE MOTOR ves, ‘SOMETIMES, Notver 1 Bone yarn kup aly th ony bing) O O oo 2. Does your baby successfully pick up a crumb or = Cheerio by using her thumb and all of her fingers in a ° ° ° raking motion? {she already picks up a crumb or wa Cheer, mark “yes" for this item.) 3. Does your baby pick up a small toy with the tips of his ‘thumb and fingers? (You should see a space between the 2 2 2 toy and his palm.) \ 4, After one or two tries, does your baby pick up a piece m= of string with her first finger and thumb? (The string ° ° ° ‘may be attached to a toy.) 5. Does your baby pick up a cumb or Chero wth he tips of his thumb and a finger? He may rest his arm or . o ° ° hand on the table while doing it. 6 Does your baby put a small toy down, without dropping it, and then take her hand off the toy? ° ° ° FINEMOTORTOTAL = —_ “IF Fine Motor Item 5 is ‘yes or “sometimes 1 Motor Item 2 mark Ages & Stages Questionnaies®, Third Edin (ASO), Spies 8 Bicker 101090301 162009 PaclH. Bracke Pubating Co. Alright sereAASQ3 9 Month Questionnaire age sors PROBLEM SOLVING ves SOMETIMES. Nor ver 1. Does your baby passa toy back and forth rom one | Sigh ° ° oO hand tothe other? g 2. Does your baby pick up two small toys, one ineach | O° O° Oo _ hand, and hold onto them for about 1 minute? 3. When holding a teyin his hand, does your baby bang eta Oo Oo oO itagainst another toy on the table? AX 4. While holding» small toyn each hand, does your baby clap the toys Oo ° o ~— together (ike "Pat-a-cake")? 5. Does your baby poke ator try to get a crumb or Cheerio thats inside a O O° oO ~— clear Bottle (such asa plastic soda-pop bottle or baby bottle)? 6 After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.) O° ° Oo _— PROBLEM SOLVING TOTAL = __. PERSONAL-SOCIAL ves SOMETIMES, Nor ver 1. While your baby is on her back, does she put her ° Oo — foot in her mouth? 2. Does your baby drink water, juice, or formula from a cup while you hold iv? 3. Does your baby feed himself a cracker or a cookie? ©0000 00 0 00 0 | 4, When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn't let go of it? (If she already lets go of the toy into your hand, mark “yes” for this item) ° ° oO — 5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve? Oo ° Oo — 6 When you hold out your hand and ask for her toy, does your baby let 90 of it into your hand? PERSONAL-‘SOCIAL TOTAL = —__ 101050401 sone scat ine gy ateAASQ3) OVERALL Parents and providers may use the space below for additional comments, 1. Does your baby use both hands and both legs equally well? Ifno, explain 9 Month Questionnaire pase sor6 Ons Ono 2. When you help your baby stand, are his feet flat on the surface most of the time? If no, explain: Os Ono XS 3. Do you have concems that your baby is too quiet or does not make sounds like other baaies? If yes, explain: 7 XN Ons Ono 4. Does either parent have a family history of childhood deafness or hearing impairment? if yes, explain: Ove Ono 5. Do you have concerns about your baby’s vision? If yes, explain 7 XN Ons Ono 6. Has your baby had ary medical prablems in the last several months? Ifyes, explain: Ove Ono XN S ‘Ages & Stages Guestionnaves, Tr Editon ASO. 1) Saures kicker 101090501 10 Sa09 Poul Broaces Pushing Ca. Allights reservedAASQ3) 9 Month Questionnaire pase 616 OVERALL ( centinuew 1. De you have any concerns about your baby’s behavior? yes, explain Ovws Ono 8 Does anything about your baby worry you yes, explain Ow Ono Va ‘Ages & Stages Qustionnsies, Third Edtion ASO), Saies& Bicker 101090601 10 Sa09 Poul Broaces Pushing Ca. Allights reserved9 Month ASQ-3 Information Summary ‘months 30 days Baby's name: Date ASQ comple Baby's #: Date of birth Administering program/provider: ‘Was age adjusted for prematurit '9 Pros! when selecting questionnaire? ~O/Yes O/No 1, SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASO-3 User's Guide for details, inclucing how to adjust scores ifitem responses are missing, Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add iter scores, and record each area total. Inthe chart below, transfer the total scores, and fillin the circles corresponding with the total scores. ares | crott Os 0 15 2058S SSO Conmuneaton | 13.97 Gross Mover | 17.82 Fine Mower | 31.32 Froalem sehing | 28.72 Peronasecat [7891 OO oO 0 0 0 0 0 2, TRANSFER OVERALL RESPONSES: Bolded uppercase responses reauite follow-up. See ASQ-3 User's Guide, Chapter 6 1. Uses both hands and both legs equally well? Yes. NO 5. Concerns about vision? YES No Comments: Comments: 2. Feet are flat on the surface most of the time? Yes. NO 6, Any medical problems? YES No Comments: Comments: 3. Concerns about not making sounds? YES No 7. Concems about behavior? YES No Comments: Comments: 4. Family history of hearing impairment? YES No & Otherconcerns? YES No Comments: Comments: 3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall responses, and ot er considerations, such as opportunities to practice sills, to determine appropriate follow-up. Ifthe baby's total score isin the (area, it's above the cutoff, and the baby’s development appears to be on schedule. If the baby's total score isin the [= area, it's close to the cutoff, Provide learning activities and monitor Ifthe baby’s total score isin the ml area, it's 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 months 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 reason): 5. OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N= NOT YET, X = response missing). 1[2]2]4[5]¢ Refer to early intervention/early childhood special education No further action taken at this time Other (specify) Problem Seleng Personal Soc [Ages & Stages Questionnsves, Tid Edtion ASQ"), Sauies& cher P101090701 162009 Pau Brookes Publshing Ca. Allright eserves