ASQ_9m

Baby's First Name

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Baby's Last Name

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Baby's Birth Date

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Boy

Girl

If baby was born 3 or more weeks prematurely, please indicate the number of weeks premature:

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Date ASQ-3 completed by parent/caregiver:

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Date of review with health professional:

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Baby’s home address:

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Town:

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Post code:

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Person completing the questionnaire:

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Relationship to baby:

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Home tel:

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Mobile no:

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All babies develop at different rates and in different ways. Please do not worry if your baby is not doing all or any of the activities mentioned in the questionnaire. It is not a test. The activities are simply one way of understanding how your baby is progressing.

Possible answers:

Yes = your baby does this activity (or has done it and has now progressed, e.g., crawling, but is now walking)

Sometimes = your baby is just beginning to do this activity (but does not do it regularly)

Not Yet = your baby has not yet started doing this

Please leave blank any activities your baby has not been able to try with you.

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 (yes), sometimes, or not yet.

Important Points to Remember:

Try each activity with your baby before marking a response.
Make completing this questionnaire a game that is fun for you and your baby.
Make sure your baby is not tired or hungry.
Please bring this questionnaire with you to your baby’s health and development review.

COMMUNICATION

1. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?

Please select an option.

2. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?

Please select an option.

3. Does your baby make two similar sounds like “ba-ba,” “da-da,” or “gaga”? (The sounds do not need to mean anything.)

Please select an option.

4. 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,” “Peekaboo,” “clap your hands,” “Pat-a-cake”)?

Please select an option.

5. Without showing her what you mean, does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back”?

Please select an option.

6. 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.

GROSS MOTOR

1. If you hold both hands just to balance your baby, does she support her own weight while standing?

Please select an option.

2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?

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3. When you stand your baby next to furniture or the cot rail, does she hold on without leaning her chest against the furniture for support?

Please select an option.

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

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

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

Please select an option.

FINE MOTOR

1. Does your baby pick up a small toy with only one hand?

Please select an option.

2. Does your baby successfully pick up a small cube of bread by using her thumb and all of her fingers in a raking motion? (If she already picks up a small cube of bread, mark “yes” for this item.)

Please select an option.

3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)

Please select an option.

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

Please select an option.

5. Does your baby pick up a small cube of bread with the tips of his thumb and a finger? (He may rest his arm or hand on the table while doing it.)

Please select an option.

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

Please select an option.

PROBLEM SOLVING

1. Does your baby pass a toy back and forth from one hand to the other?

Please select an option.

2. Does your baby pick up two small toys, one in each hand, and hold on to them for about 1 minute?

Please select an option.

3. When holding a toy in his hand, does your baby bang it against another toy on the table?

Please select an option.

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

Please select an option.

5. Does your baby poke at or try to get a raisin that is inside a clear plastic bottle (such as a small water bottle or baby bottle)?

Please select an option.

6. 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.

PERSONAL-SOCIAL

1. While your baby is on her back, does she put her foot in her mouth?

Please select an option.

2. Does your baby drink water, juice, or formula from a cup while you hold it?

Please select an option.

3. Does your baby feed himself finger foods such as a cracker, a chapati, or a biscuit?

Please select an option.

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

Please select an option.

5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?

Please select an option.

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

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. When you help your baby stand, are his feet flat on the surface most of the time?

Please select an option.

If no, explain:

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

Please select an option.

If yes, explain:

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4. Does either parent have a family history of childhood deafness or hearing problems?

Please select an option.

If yes, explain:

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5. Do you have concerns about your baby’s eyesight?

Please select an option.

If yes, explain:

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6. Has your baby had any medical or health-related problems in the last few months?

Please select an option.

If yes, explain:

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7. Do you have any concerns about your baby’s behaviour?

Please select an option.

If yes, explain:

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8. Does anything about your baby worry you?

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If yes, explain:

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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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