Transcription of Ages & Stages Questionnaires 18 Month …
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Ages & Stages Questionnaires 18 Month …
ages & Stages Questionnaires , Third Edition (ASQ-3 ),Squires & Bricker 2009 Paul H. Brookes Publishing Co. All rights filling out questionnaireChild s informationDate ASQ completed:Relationship to child:ParentStreet address:Names of people assisting in questionnaire completion:Grandparent or other relativeGuardianFoster parentTeacherChild care providerOther: ages & StagesQuestionnaires Month Questionnaire17 months 0 days through 18 months 30 daysPlease provide the following information. Use black or blue ink only and printlegibly when completing this s first name:Child s last name:Child s date of birth:First name:Last name:Middle initial:City:Home telephone number:State/Province:ZIP/Postal code:Other telephone number:E-mail address:If child was born 3 or more weeks prematurely, # ofweeks premature:Child s gender:MaleFemaleMiddle initial:Country:Program InformationAge at administration in months and days:Child ID #:Program ID #:Program name:If premature, adjusted age in months and days: ages & Stages Questionnaires , Third Edition (ASQ-3 ),Squires & Bricker 2009 Paul H.
GROSS MOTOR 1. Does your child bend over or squat to pick up an object from the floor and then stand up again without any support? 2. Does your child move around by walking, rather than by crawling on
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