ASQ_15-16m

Child’s first name:

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M.I

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Patient Last Name

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Child’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

Child 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 child point to, pat, or try to pick up pictures in a book?

Please select an option.

2. Does your child say four or more words in addition to “Mama” and “Dada”?

Please select an option.

3. When your child wants something, does she tell you by pointing to it?

Please select an option.

4. When you ask your child to, does he 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.”)

Please select an option.

5. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as “Mama eats,” “Daddy play,” “Go home,” or “What’s this?” does your child say both words back to you? (Mark “yes” even if her words are difficult to understand.)

Please select an option.

6. Does your child say eight or more words in addition to “Mama” and “Dada”?

Please select an option.

GROSS MOTOR

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

Please select an option.

2. Does your child climb onto furniture or other large objects, such as large climbing blocks?

Please select an option.

3. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support?

Please select an option.

4. Does your child move around by walking, rather than crawling on her hands and knees?

Please select an option.

5. Does your child walk well and seldom fall?

Please select an option.

6. Does your child climb on an object such as a chair to reach something he wants (for example, to get a toy on a counter or to “help” you in the kitchen)?

Please select an option.

FINE MOTOR

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

Please select an option.

2. Does your child 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.

3. Does your child 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.)

Please select an option.

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

Please select an option.

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

Please select an option.

6. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)

Please select an option.

PROBLEM SOLVING

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

Please select an option.

2. Can your child drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?

Please select an option.

3. Does your child drop several small toys, one after another, into a container like a bowl or box? (You may show him how to do it.)

Please select an option.

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

Please select an option.

5. Without your showing him how, does your child scribble back and forth when you give him a crayon (or pencil or pen)?

Please select an option.

6. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle upside down to dump it out? (You may show her how.)

Please select an option.

PERSONAL-SOCIAL

1. Does your child feed himself with a spoon, even though he may spill some food?

Please select an option.

2. Does your child help undress herself by taking off clothes like socks, hat, shoes, or mittens?

Please select an option.

3. Does your child play with a doll or stuffed animal by hugging it?

Please select an option.

4. While looking at himself in the mirror, does your child offer a toy to his own image?

Please select an option.

5. Does your child get your attention or try to show you something by pulling on your hand or clothes?

Please select an option.

6. Does your child come to you when she needs help, such as with winding up a toy or unscrewing a lid from a jar?

Please select an option.

OVERALL

1. Do you think your child hears well?

Please select an option.

If no, explain:

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2. Do you think your child talks like other toddlers his age?

Please select an option.

If no, explain:

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3. Can you understand most of what your child says?

Please select an option.

If no, explain:

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4. Do you think your child walks, runs, and climbs like other toddlers her age?

Please select an option.

If no, 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 child’s vision?

Please select an option.

If yes, explain:

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7. Has your child 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 child’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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