ASQ 12 M

Baby’s first name:

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M.I

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Baby's Last Name

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Baby's date of birth:

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

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Child’s gender:

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Person filling out questionnaire

First name:

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M.I

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Last name:

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Street address:

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Relationship to child:

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Other:

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City:

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State / Province:

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ZIP / Postal code:

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Country:

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Home telephone number:

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Other telephone number:

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Email Address:

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Names of people assisting in questionnaire completion:

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Program Information

Baby ID #:

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Age at administration in months and days:

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Program ID #:

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If premature, adjusted age in months and days:

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Program name:

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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 choose whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:

Tryeachactivitywithyourbabybeforemarkingaresponse.
Make completing this questionnaire a game that is fun for you and your child.
Make sure your child is rested and fed.
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, try the activities when your child is cooperative. If your child can do the activity but refuses, mark “yes” for the item.

COMMUNICATION

1. Does your baby make two similar sounds, such as "ba-ba," "da-da," or “ga-ga”? (The sounds do not need to mean anything.)

Please select an option.

2. If you 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," "Peeka- boo," "clap your hands," “So Big”)?

Please select an option.

3. Does your baby follow one simple command, such as "Come here," “Give it to me,” or "Put it back," without your using gestures?

Please select an option.

4. 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.)

Please select an option.

5. When you ask, “Where is the ball (hat, shoe, etc.)?” does your baby look at the object? (Make sure the object is present. Mark "yes" if she knows one object.)

Please select an option.

6. When your baby wants something, does he tell you by pointing to it?

Please select an option.

GROSS MOTOR

1. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?

Please select an option.

2. While holding onto furniture, does your baby lower herself with control (without falling or flopping down)?

Please select an option.

3. Does your baby walk beside furniture while holding on with only one hand?

Please select an option.

4. 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.)

Please select an option.

5. 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.)

Please select an option.

6. Does your baby stand up in the middle of the floor by himself and take several steps forward?

Please select an option.

FINE MOTOR

1. After one or two tries, does your baby pick up a piece of string with his first finger and thumb? (The string may be attached to a toy.)

Please select an option.

2. Does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger? She may rest her arm or hand on the table while doing it.

Please select an option.

3. Does your baby put a small toy down, without dropping it, and then take his hand off the toy?

Please select an option.

4. 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?

Please select an option.

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

Please select an option.

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

Please select an option.

PROBLEM SOLVING

1. When holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?

Please select an option.

2. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?

Please select an option.

3. 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.)

Please select an option.

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

Please select an option.

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

Please select an option.

6. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If she already scribbles on her own, mark “yes” for this item.)

Please select an option.

PERSONAL-SOCIAL

1. When you hold out your hand and ask for his toy, does your baby offer it to you even if he doesn't let go of it? (If he already lets go of the toy into your hand, mark “yes” for this item.)

Please select an option.

2. When you dress your baby, does she push her arm through a sleeve once her arm is started in the hole of the sleeve?

Please select an option.

3. When you hold out your hand and ask for his toy, does your baby let go of it into your hand?

Please select an option.

4. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?

Please select an option.

5. Does your baby roll or throw a ball back to you so that you can return it to him?

Please select an option.

6. Does your baby play with a doll or stuffed animal by hugging it?

Please select an option.

OVERALL

1. Does your baby use both hands and both legs equally well?

Please select an option.

If no, explain:

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2. Does your baby play with sounds or seem to make words?

Please select an option.

If no, explain:

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3. When your baby is standing, are her feet flat on the surface most of the time?

Please select an option.

If yes, explain:

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4. Do you have concerns that your baby is too quiet or does not make sounds like other babies do?

Please select an option.

If yes, explain:

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5. Does either parent have a family history of childhood deafness or hearing impairment?

Please select an option.

If yes, explain:

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6. Do you have concerns about your baby's vision?

Please select an option.

If yes, explain:

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7. Has your baby had any medical problems in the last several months?

Please select an option.

If yes, explain:

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8. Do you have any concerns about your baby’s behavior?

Please select an option.

If yes, explain:

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9. Does anything about your child worry you?

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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