l{ baby was born 3 or more weeks prematurely, # o{ weeks premature: Last name Relationship to baby: State/ Province Home telephone number:

Size: px

Start display at page:

Download "l{ baby was born 3 or more weeks prematurely, # o{ weeks premature: Last name Relationship to baby: State/ Province Home telephone number:"

Neal Anthony
8 years ago
Views:

1 9 mnths 0 days thrugh 9 mnths 30 days Mnth Ouestinnaire Please prvide the fllwing infrmatin. se black r blue ink nly and print legibly when cmpleting this frm. Date ASQ cmpleted:,,b:by's.infi;nat!ri Middle Baby's date f birth l{ baby was brn 3 r mre weeks prematurely, # { weeks premature: Baby's gender: Q urt" O r".ul" Pelsgn filling ut questinnaire First name: Street address: Middle initial: Last name Relatinship t baby: O Pu,"n, Q c,ardian 7-\ Grandparent /-\ Fster \-/ rther \-./ parent relative Teacher fi v Other: child.uru prvrder ity: State/ Prvince ZIP/ Pstal cde: Hme telephne number: Other telephne numbet: address Names f peple assis Prgram lnfrmatin Baby ld #: Age at administratin in mnths and days: P10i090i00 Ages & Stages Ouestinnaires@, Third Editin (ASQ'31M), Squires & 2009 Paul H. Brkes Publishing. All rights reserved.

$ul" Pelsgn filling ut questinnaire First name: Street address: Middle initial: Last name Relatinship t baby: O Pu,"n, Q c,ardian 7-\ Grandparent /-\ Fster \-/ rther \-.$

2 Jularly, smetimes, r. nt yet. lmprtant Pints t Remember: d Try each activity with yur baby befre marking a respnse. d Make cmpleting this questinnaire a game that is fun fr yu and yur baby. d Make sure yur baby is rested and fed. d Please return this questinnaire by OMMNIATION 1. Des yur baby make sunds like "da," "ga," "ka," and "ba"? 2. lf yu cpy the sunds yur baby makes, des yur baby repeat the same sunds back t yu? 3. Des yur baby make tw similar sunds like "ba-ba," "da-da," r "ga-ga"? (The sunds d nt need t mean anything.) 4. lf yu ask yur baby t, des he play at least ne nursery game even if yu dn't shw her the activity yurself (such as "bye-bye," "Peekab," "clap yur hands," "S Big")? 5. Des yur baby fllw ne simple cmmand, such as "me here," "Give it t me," r "Put it back," withut yur using gestures? 6. Des yur baby say three wrds, such as "Mama," "Dada," and "Baba"? (A "wrd" is a sund r sunds yur baby says cnsistently t mean smen e r smething.) SOIMETIMES NOT YET OIVlMNIATION TOTAL GROSS MOTOR SOMETIMES 'l. lf yu hld bth hands just t balance yur baby, des she supprt her wn weight while standing? When sitting n the fll des yur baby sit up straight fr several minutes withut using his hands fr supprt? E Ages & Stages Questinnaires@, Third Editin (ASQ-3ru,1, Squires & 2009 Paul H. Brkes Publishing. All rights reserved. page 2 f 6

lf yu cpy the sunds yur baby makes, des yur baby repeat the same sunds back t yu? 3. Des yur baby make tw similar sunds like "ba-ba," "da-da," r "ga-ga"? (The sunds d nt need t mean anything.) 4.

3 (EASQQ 9 Mnth Q,uestinnaire p,gesre GROSS MOTOR bntinued) SOMETIMES NOT YET 3, When yu stand yur baby next t furniture r the crib rail, des she hld n withut leaning her chest against the furniture fr supprt? tl 4. While hlding nt furniture, des yur baby bend dwn and pick up a ty frm the flr and then return t a standing psitin? t While hlding nt furniture, des yur baby lwer himself with cntrl (withut falling r flpping dwn)? (J Des yur baby walk beside furniture while hlding n with nly ne hand? t GROSS MOTOR TOTAL FINE MOTOR 1. Des yur baby pick up a small ty with nly ne hand? SOlr/ETIMES NOT YET 2. Des yur baby successfully pick up a crumb r heeri by using her thumb and all f her fingers in a raking mtin? (lf she already picks up a crumb r heeri, mark "yes" fr this item.) Des yur baby pick up a small ty with the trps f his thumb and fingers? (Yu shuld see a space between the ty and his palm.) ffit*- \ % t 4. After ne r tw tries, des yur baby pick up a piece f string with her first finger and thumb? (The string may be attached t a ty.) Des yur baby pick up a crumb r heeri with the trps f his thumb and a finger? He may rest his arm r hand n the table while ding it Des yur baby put a small ty dwn, withut drpping it, and then O take her hand ff the ty? FINE MOTOR TOTAL *lf Fie Mtr ltem 5 is marked "yes" r "smetimes," ntark Fine Mtr ltern 2 "yes." E Ages & Stages Ouestinnaires@, Third Editin (ASQ-:ru,), Squires & 2009 Paul H. Brkes Publishing. All rights reserued.

t While hlding nt furniture, des yur baby lwer himself with cntrl (withut falling r flpping dwn)? (J Des yur baby walk beside furniture while hlding n with nly ne hand?

4 GINQQ PROBLEM SOLVING 1. Des yur baby pass a ty back and frth frm ne hand t the ther? 9 Mnth Ouertinn"ir" p,g"nru SOMETIMES NOT YET 2. Des yur baby pick up tw small tys, ne in each hand, and hld nt them fr abut 1 minute? 3. When hlding a ty in his hand, des yur baby bang it against anther ty n the table? While hlding a small ty in each hand, des yur baby clap the tys tgether (like " Pat-a-cake")? 5. Des yur baby pke at r try t get a crumb r heeri that is inside a clear bttle (such as a plastic sda-pp bttle r baby bttle)? After watching yu hide a small ty under a piece f paper r clth, des yur baby find it? (Be sure the ty is cmpletely hidden.) {) PROBLEM SOLVING TOTAL PERSONAL-SOIAL SOMETIMES NOT YET 1. While yur baby is n her back, des she put her ft in her muth? Des yur baby drink water, juice, r frmula frm a cup while yu hld it? Des yur baby feed himself a cracker r a ckie? When yu hld ut yur hand and ask fr her ty, des yur baby ffer it t yu even if she desn't let g f it? (lf she already lets g f the ty int yur hand, mark "yes" fr this item.) When yu dress yur baby, des he push his arm thrugh a sleeve nce his arm is started in the hle f the sleeve? When yu hld ut yur hand and ask fr her ty, des yur baby let g f it int yur hand?.) (-, t, PERSONAL-SOIAL TOTAL E Ages & Stages Questinnaires@, Third Editin (ASa-yu1, Squires & 2009 Paul H. Brkes Publishing. All rights reseryed.

While hlding a small ty in each hand, des yur baby clap the tys tgether (like " Pat-a-cake")? 5.

5 9 Mnth Q.uestinnaire OVERALL parents and prviders may use the space belw fr additinal cmments. 1. Des yur baby use bth hands and bth legs equally well? lf n. explain: ".t O* 2. When yu help yur baby stand, are his feet flat n the surface mst f the time? lf n, explain: O rrt O^ 3. D yu have cncerns that yur baby is t quiet r des nt make sunds like ther babies? lf Yes, explain: "=s O* 4. Des either parent have a family histry f childhd deafness r hearing impairment? lf Yes, explain: O ".t Or 5. D yu have cncerns abut yur baby's visin? lf yes, explain: t.t O* 6. Has yur baby had any medical prblems in the last several mnths? lf yes, explain: "ut O* E Aes & Staqes Ouestinnaires@, Third Editin (ASO-3TM), Squires & Bricker O iog paul H. Brkes Publishing All rights reserved'

lf Yes, explain: "=s O* 4. Des either parent have a family histry f childhd deafness r hearing impairment? lf Yes, explain: O ".t Or 5. D yu have cncerns abut yur baby's visin? lf yes, explain: t.

7 [d,nq-3 9 Mnth Questinnaire p'g"6r6 OVERALL kn{tnued) 7. D yu have any cncerns abut yur baby's behavir? lf yes, explain: *r O* 8. Des anything abut yur baby wrry yu? lf yes, explain: Ot E Ages & Stages Ouestinnaires@, Third Editin (ASO-3ru,;, Squires & Bricker - O 20s Paul H. Brkes Publishing. All rights reserued.

8 p runth AS-3 lnfrmatin Summarlr '^'*Fl!:{;,'!,j.j:1, Baby's name Baby's ld #: Administering prgram/prvider: Date ASQ cmpleted Date f birth: Was age adjusted fr prematurity whjn selecting questinnairei Q v", O ru 1. SORE AND TRANSFER TOTALS TO HART BELOW: See A5O-3 ser's Guide fr details, including hw t adjust scres if item respnses are missing. Scre each item ( = 10, SOMETIMES = 5, NOT YEf : 0). Add item scres, and recrd each area ttal. ln the chart belw, transfer the ttal scres, and fill in the circles crrespnding with the ttal scres. mmunicatin Grss Mtr Fine Mtr Prblem Slving Persnal-Scial utff Ttal Scre 2. IRANSFER OVERALL RESPONSES: Blded uppercase respnses require fllw-up. See ASO-3 ser's Guide, hapter 6. 1, ses bth hands and bth legs equally well? mments: Yes NO 5. ncerns abut visin? mments: N t_ Feet are flat n the surface mst f the time? mments: Yes NO Any medical prblems? mments: N ncerns abut nt making sunds? mments: N 7. ncerns abut behavir? mments: N 4, Family histry f hearing impairment? mments: YE5 N 8. Other cncerns? mments: N 3. ASO SORE INTERPRETATION AND REOMMENDATION FOR FOLLOW-P: Yu must cnsider ttal area scres, verall respnses, and ther cnsideratins, such as pprtunities t practice skills, t determine apprpriate fllw-up. lf the babyt ttal scre is in the [---'1 area. it is abve the cutff, and the baby's develpment appears t be n schedule. lf the baby's ttal scre is in the [--l area, it is clse t the cutff. Prvide learning activities and mnitr. lf the baby's ttal scre is in the I area. it is belw the cutff. Further assessment with a prfessinal may be needed. 4. FOLLOW-P ATION TAKEN: heck allthat apply. Prvide activities and rescreen in - mnths. Share results with primary health care prvider. Refer fr (circle all that apply) hearing, visin, and/r behaviral screening Refer t primary health care prvider r ther cmmunity agency (specify reasn): Refer t early interventin/early childhd special educatin. N further actin taken at this time Other (specify): 5. OPTIONAL: Transfer item respnses (Y =, S : SOMETIMES, N : NT YET, X = respnse missing). mmunicatin Grss Mtr Fine Mtr Prblem Slving Persna l-scia I P Ages & Stages Ouestinnaires@, Third Editin (ASQ-3rM), Squires & Bricker O 2009 Paul H. Brkes Publishing. All rights reserved,

SORE AND TRANSFER TOTALS TO HART BELOW: See A5O-3 ser's Guide fr details, including hw t adjust scres if item respnses are missing. Scre each item ( = 10, SOMETIMES = 5, NOT YEf : 0).

If baby was born 3 or more weeks prematurely, # of weeks premature: Last name: State/ Province: Home telephone number:

If baby was born 3 or more weeks prematurely, # of weeks premature: Last name: State/ Province: Home telephone number: Ages & Stages Questionnaires 10 9 months 0 days through 10 months 30 days Month Questionnaire Please provide the following information. Use black or blue ink only and print legibly when completing this