ASQ

íãÃSQ-31 Ages & Stages

’ Questionnaires®

I ¿r Month Questionnaire

O Male O

Baby's information

Person filling out questionnaire

Program Information

P101140101

COMMUNICATION

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

OVERALL

COMMUNICATION TOTAL

EW114020I

FINE MOTOR TOTAL

E101140301

PROBLEM SOLVING TOTAL

E101140401

E101140501

E101140601

P101140701

GROSS MOTOR TOTAL

trainedthoughts

14_Month_ASQ1.html

Home >Education homework help >ASQ

Æ 13 months 0 days through 14 months 30 days

Please provide th’e following information. Use black or blue ink only and print legibly when completing this form.

Date ASQ completed:

Baby's first name:

Baby's date of birth:

Middle initial:

Baby's last name:

If baby was born 3 or more weeks prematurely, # of weeks premature:

Baby's gender:

First name:

Middle initial:

Street address:

Last name:

Relationship to baby:

(^) Parent Guardian

Grandparent Foster
r other parent

relative

State/ Province:

ZIP/

Postal code:

Country:

Home telephone number:

Other telephone number:

E-mail address:

Names of people assisting in questionnaire completion:

Baby ID#:

Program ID #:

Age at administration in months and days:

If premature, adjusted age in months and days:

Program name:

Ages & Stages Questionnaires®, Third Edition (ASQ-3rM), Squires & Bricker

ASQ3j1 4 Month Questionnaire thmugh s3°dda£
thefoííowíng 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 begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remëmber: Notes:

EÍ Try each activity with your baby before marking a response. »

EÍ Make completing this questionnaire a game that is fun for you and your baby.

Make sure your baby is rested and fed. -----------

Please return this questionnaire by
this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your baby more than one time. If possible, try the activities when your baby is cooperative. If your baby can do the activity but refuses, mark "yes" for the item. ‘

Does your baby say three words, such as "Mama," "Dada," and "Baba"? (A "word" is a sound or sounds your baby says consistently to mean someone or something.)
When your baby wants something, does she tell you by pointing to it?
Does your baby shake his head when he means "no" or "yes"?
Does your baby point to, pat, or try to pick up pictures in a book?
Does your baby say four or more words in addition to "Mama" and "Dada"?
When you ask her to, does your baby go into another room to find a familiar toy or object? (You might ask, "Where is your ball?" or say, "Bring me your coat," or "Go get your blanket.")

YES	SOMETIMES o	NOT YET
o	o	o
	o	o I
o	o	(2)
(2)	o	o
o	o	o	........—*

1. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark "yes" for this item.)

2. When you hold one hand just to balance your baby, does she take several steps forward? (If your baby already walks alone, mark "yes" for this item.)

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

NOT YET

page 2 of 6

14 Month Questionnaire

page 3 of 6

i^ASQ-3)

GROSS MOTOR (continued)

Does your baby stand up in the middle of the floor by himself and take several steps forward?
Does your baby climb onto furniture or other large objects, such as large climbing blocks?
Does your baby bend over or squat to pick up an obj'ect from the floor and then stand up again without any support?
Does your baby move around by walking, rather than by crawling on his hands and knees?

YES	SOMETIMES o	NOT YET
(2)	. o	(2)
o	o	o.
^2)	o	o

YES

1. Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?

Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark "not yet" for this item.)

Does your baby help turn the pages of a book? (You may lift a page for her to grasp.)

Does your baby stack a small block or toy on top of another one? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)

Does your baby make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?

Does your baby stack three small blocks or toys on top of each other by herself?

SOMETIMES

NOT YET

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

aAsoą

1. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although he may not let go of it? (If he already lets go of the toy into a bowl or box, mark "yes" for this item.)

Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show her how to do it.)

After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If he already scribbles on his own, mark "yes" for this item.)
Can your baby drop a crumb or Cheerio into a small, clèar bottle (such as a plastic soda-pop bottle or baby bottle)?
Does your baby drop'several small toys, one after another, into a container like a bowl or box? (You may show her how to do it.)

After you have shown your baby how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?

14 Month Questionnaire page 4 of 6

YES SOMETIMES NOT YET

PERSONAL-SOCIAL TOTAL

*lf Problem Solving Item 2 is marked "yes" or "sometimes," mark Problem Solving Item 1 as "yes. "

PERSONAL-SOCIAL	YES	SOMETIMES	NOT YET
1. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?	Q)		O —
2. Does your baby roll or throw a ball back to you so that you can return it to him?	o		O —
3. Does your baby play with a doll or stuffed animal by hugging it?		o	o —
4. Does your baby feed herself with a spoon, even though she may spill some food?	o	o	_
5. Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?		o	O —
6. Does your baby get your attention or try to show you something by pulling on your hand or clothes?	o	o	O —

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

14 Month Questionnaire page 5 of 6

OVERALL
Parents and providers may use the space below for additional comments.
1. Does your baby use both hands and both legs equally well? If no, explain:	O YES	O NO
V
2. Does your baby play with sounds or seem to make words? If no, explain:	O yes	O NO
1
3. When your baby is standing, are her feet flat on the surface most of the time? If no, explain:	O yes	O NO

4. Do you have concerns that your baby is too quiet or does not make sounds like other babies do? If yes, explain:	O YES	O NO

5. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:

Ages & Stages Questionnaires®, Third Edition (ASQ-3'™), Squires & Bricker

SŁASO-ą

(continued)

6. Do you have concerns about your baby's vision? If yes, explain:

14 Month Questionnaire page 6 of 6

O YES

Has your baby had any medical problems in the last several months? If yes, explain:

you have any concerns about your baby's behavior? If yes, explain:

9. Does anything about your baby worry you? If yes, explain:

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

[CASOSI

M Month ASQ-3 Information Summary 13 mon^s

J 74 months 3U days

Baby's name:. Date ASQ completed:

Baby's ID ft:

Administering program/provider:---------------------------------------------------------—

Date of birth: ________________________________________________

Was age adjusted for prematurity

when selecting questionnaire? (2) Yes Q Nq

1. SCORE AND TRANSFER TOTALS TO CHART BELOW; See ASQ-3 User's Guide for details, including how to adjust scores if item responses are missing. Score each item (YES =10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total. In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.

Area	Cutoff		30	35	40	45	50	55	60
Communication	17.40	¡SÍ ^0 5 10 15 -20 25	O	q	q	o	o	o	o
Gross Motor	25.80		„ Q		•ö	o	o	o	o
Fine Motor	23.06	■ » mi —--—"Win y	■ o	M0	(2)	o	o	o	o
Problem Solving	22.5Ó		o.	MO	o	Q	Q	o	o
Personal-Social	23.18	CD-	o	M^_	(2)	o	o	o	o

2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6.

1.	Uses both hands and both legs equally well? Comments:	Yes	NO	6.	Concerns about vision? Comments:	YES	No
2.	Plays with sounds or seems to make words? Comments:	Yes	NO	7.	Any medical problems? Comments:	YES	No
3.	Feet are flat on the surface most of the time? Comments:	Yes	NO	8.	Concerns about behavior? Comments:	YES	No
4.	Concerns about not making sounds? Comments:	YES	No	9.	Other concerns? Comments:	YES	No
5.	Family history of hearing impairment? Comments:	YES	No

ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
the baby's total score is in the £□ area, it is above the cutoff, and the baby's development appears to be on schedule.
the baby's total score is in theUZZI area, it is close to the cutoff. Provide learning activities and monitor.
the baby's total score is in the ■■ area, it is below the cutoff. Further assessment with a professional may be needed.
FOLLOW-UP ACTION TAKEN: Check all that apply.

Provide activities and rescreen inmonths.

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):.

Referto early intervention/early childhood special education.

No further action taken at this time

Other (specifỳ):

5. OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X = response missing).

Communication

Grofes Motor

Fine Motor

Problem Solving

Personal-Social

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker