Ages & Stages Questionnaires 72 Month Questionnaire 72 months 0 days through 78 months 0 days ASQ3 72month Pilot Version Please provide the following information. Please print clearly when completing this form. Date ASQ completed: Child s Information Child s first name: Middle initial : Child s last name : Child s date of birth: Child s gender : male female Person Filling out questionnaire First name: Middle initial: Last name : Relationship to child: Parent Guardian Teacher Childcare provider Grandparent/other relative Foster parent Other Street address: City: State/Province: Zip/postal code: Country: Home telephone: Other telephone: :Email address: Names of people assisting in questionnaire completion: Program Information Child ID#: Program ID # Program name: : 66 month ASQ-3 pilot version 1.0 1
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 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 Remember: Try each activity with your child before marking a response. Make completing this questionnaire a game that is fun for you and your child. Make sure your child is rested and fed before trying activities. Please return this questionnaire by: 72 Month Questionnaire 72 months 0 days through 78 months 0 days Notes: Communication 1.After hearing new words, does your child try to use them in conversation? Yes Sometimes Not Yet 2. Does your child use at least 5 words to describe position? Foe example, does he/she use words such as above, across, around, between, below, near, over, and through. 3. Does your child repeat the sentences shown below back to you, without any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark yes if your child repeats both sentences without mistakes or sometimes if your child repeats one sentence without mistakes.) 4. Does your child use comparison words, such as heavier, stronger, or shorter? Ask your child questions, such as A car is big, but a bus is (bigger); A cat is heavy, but a man is (heavier); A TV is small, but a book is (smaller). 2
Communication (continued) Yes Sometimes Not Yet 5. After reading a new story to your child, can your child tell you the beginning, middle, and ending the story (you can help the child by saying, How does the story begin? )? 6. Does your child use words that connect other words such as and, but, because, if, and or,? For example, Your child says, We could play or take a nap. Communication Total 3
Gross Motor Yes Sometimes Not Yet 1. Does your child catch a small ball (such as a tennis ball) that is thrown from 6 feet (3 adult walking steps) away? 2. Ask your child to repeat a movement pattern of hop up, jump and skip a few steps. Does your child do all three movements at least 2 times? (You may show him how to do it)? 3. Does your child jump forward a distance of 3 feet (one long adult walking step) from a standing position? He/she should start with his/her feet together. (Mark sometimes if child looses his/her balance)? 4. Show your child how to walk backward by placing the toe of one foot in back of the other foot, touching the heel of the other foot. Does your child walk 10 or more steps backward? 5. Does your child hop forward on one foot for a distance of 6 feet (3 adult walking steps) without putting down the other foot? You may give him/her two tries on each foot. Mark sometimes if he/she can hop on one foot only. 6. Does your child throw a small ball (such as a tennis ball) about 12 feet (5 adult walking steps) and hit a target about (2x2 feet) or a size of a large pizza box? Gross Motor Total 4
Fine Motor Yes Sometimes Not Yet 1. Does your child button most on his/her clothing, including small buttons less than 1/2 inche? (About the size of a penny) 2. Give your child an 8 1/2 by 11 inch piece of paper (regular A-4 size) and ask him/her to fold the short sides together. Does your child fold the paper so that the sides match up within a half inch? 3. Does your child cut up soft food such as pizza into smaller pieces using a dull knife in one hand and a fork in the other? Carefully watch your child s use of dull knife and fork for safety reasons.) 4. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child to Draw a picture of a girl or boy. If your child draws a person with head, body, arms, and legs, mark yes. If your child draws a person with only three parts (head, body, arms or legs), mark sometimes. If your child draws a person with two or fewer parts (head, body, arms, or legs), mark, not yet. 5
Fine Motor (continued) Yes Sometimes Not Yet 5. Using the letters below to look at, does your child copy the letters without tracing? Cover up all of the letters except the letter being copied. Mark yes if your child copies four of the letters, and you can read them. Mark sometimes if your child copies two or three letters and you can read them. V H T C A (Copy letters here.) 6. Does your child cut a 4 inch line across paper that is thick paper (such as light cardboard) Fine Motor Total 6
Problem Solving Yes Sometimes Not Yet 1. Ask your child, What is 4 plus 2, 3 plus 5, 7 plus 1. Does your child correctly add the numbers? They can use their fingers to count. 2. Can your child count to 100 by 10 s? (For example, 10, 20, 30...) 3. Ask your child, What is 6 minus (or take away) 1, 4 minus 2, and 8 minus 3? Does your child correctly subtract one number from another? They can use their fingers to count. 4. Does your child know the sounds of 5 of these letters? S, t, k, m, p, c, f, j. 5. Ask your child, What day comes before and after Friday? Does your child answer correctly? Mark sometimes if your child can name one of the days. You can say, What day comes before Friday? and What day comes after Friday? Please delete numbers 6. Does your child tell you if a spoken or printed word has the same or different beginning and ending sounds? For example, CAR and CAKE have the same beginning sounds. BEG and DOG have the same end sounds. MAMA and LAMA have different beginning sounds. TOP and TOY have different ending sounds. Problem Solving Total 7
Personal Social Yes Sometimes Not Yet 1. Does your child take turns when playing a sit down game such as board games or cards? 2. Does your child ask before using other people s things? 3. Does your child begin activities and encourage friends to join in? For example, does your child say, Come on, and let s build a house. You make the garage. 4. Does your child try to solve a conflict with playmates? Foe example, your child might say, I ll play with the ball first, and then it s your turn. 5. Does your child use the toilet by yourself? For example, he/she goes to the bathroom, sits on the toilet, wipes, and flushes.) Mark yes even if he/she does this after you remind him/her. 6. Does your child do most of the bath time routine by himself/herself (under your supervision))? For example: Does he/she take off clothes, get into the tub, clean her/his body, and dry herself/ himself off? Personal Social Total 8
Overall 1. Do you think your child hears well? If no, explain: 2. Do you think your child talks like other children her age? If no, explain: 3. Can you understand most of what your child says? If no, explain: 4. Can other people understand most of what your child says? If no, explain: 5. Do you think your child walks, runs, and climbs like other children his age? If no, explain: 9
Overall 6. Does either parent have a history of childhood deafness or hearing impairment? If yes, explain: 7. Do you have concerns about your child s vision? If yes, explain: 8. Has your child had any medical problems in the last several months? If yes, explain: 9. Do you have any concerns about your child's behavior? If yes, explain: 10. Does anything about your child worry you? If yes, explain: 10