Ages & Stages Questionnaires - Michael Taymor, MD

1 Ages & StagesQuestionnaires A Parent-CompletedChild Monitoring SystemTHIRD EDITIONbyJane Squires, ,& Diane Bricker, assistance from Elizabeth Twombly, ,Robert Nickel, , Jantina Clifford, ,Kimberly Murphy, Robert Hoselton, LaWanda Potter, ,Linda Mounts, , & Jane Farrell, 2009 by Paul H. Brookes Publishing rights reserved. Paul H. Brookes Publishing Co. is a registered trademark ofPaul H. Brookes Publishing Co. & Stages Questionnaires is a registered trademarkandis a trademark of Paul H. Brookes Publishing Co., London SydneyASQ-3 CD-ROMA bout This CD-ROMThis CD-ROM contains 1) your End User License agreement , 2) printable ASQ-3 PDFs, 3) infor-mation about ASQ, 4) information about the authors, 5) training information, and 6) order ASQ-3 PDFs are organized as a single comprehensive set and also within six individual foldersto help you easily locate and print the specific materials you need. The master set ( Master ) includes in a single PDF file all ASQ-3 Questionnaires ,cover sheets (family information sheets) in data template format, scoring sheets (Information Sum-mary sheets), intervention activities, and supplemental materials.

2 You may print this PDF in itsentirety, or you may print specific pages of this PDF by clicking the appropriate bookmark in thePDF, selecting Print, and typing the corresponding page number(s) you wish to print. The materials included in Master are also organized in six folders to facilitate youruse of ASQ-3. You may print the contents of these folders as needed. The contents of the six foldersare as follows (and the contents of Sets A D are summarized in the chart on the next page):Set A: 21 PDFs, one for each questionnaire plus its corresponding standardfamily informationsheet. Convenient for users who want to print a questionnaire with a family-friendly familyinformation sheet and who do NOT need to print the Information Summary sheetSet B: 21 PDFs, one for each individual questionnaire plus its corresponding standardfamily infor-mation sheet and Information Summary sheet. Convenient for users who want to print a ques-tionnaire with a family-friendly family information sheet and Information Summary sheetSet C: 21 PDFs, one for each questionnaire plus its corresponding data templatefamily informationsheet.

3 Convenient for users who want to print a questionnaire with a family information sheetdesigned to improve legibility and support data management and who do NOT need to printthe Information Summary sheetSet D: 21 PDFs, one for each individual questionnaire plus its corresponding data templatefamilyinformation sheet. Convenient for users who want to print a questionnaire with a family infor-mation sheet designed to improve legibility and support data management and an InformationSummary sheetIntervention activities: 11 age-appropriate intervention activity sheets that may be provided to par-ents or other caregiversSupplemental materials: What Is ASQ-3 ?, a mailing sheet, Parent Conference Sheet, and ChildMonitoring SheetIndividual Standard familyData template familyInformation questionnairesinformation sheetsinformation sheetsSummary sheetsSet ASet BSet CSet DYou may print and photocopy these PDF documents from a computer located within yourown facilities at a single physical site in the course of your service provision to children and theirfamilies.

4 Printed copies may only be made from this original ASQ-3 CD-ROM. Electronicreproduction is prohibited. These PDFs may also be posted on and printed from a local areanetwork (LAN) provided that all other stipulations of the End User License agreement are metand all employees with access to the PDFs on this CD-ROM work at the same physical site asthe purchaser. This CD-ROM cannot be shared among agency sites. See the End User LicenseAgreement for further details regarding conditions related to the posting and printing of thefiles on this Set ContentsFor individual files of the Questionnaires with and without summaries, see the folders on thisCD-ROM. See About This CD-ROM for more information about the file sets on this This CD-ROM ..2 3 ASQ-3 Questionnaires (with data template family information sheets)2 Month ASQ-3 ..6 102 Month ASQ-3 Information Summary ..114 Month ASQ-3 ..12 164 Month ASQ-3 Information Summary ..176 Month ASQ-3.

5 18 236 Month ASQ-3 Information Summary ..248 Month ASQ-3 ..25 308 Month ASQ-3 Information Summary ..319 Month ASQ-3 ..32 379 Month ASQ-3 Information Summary ..3810 Month ASQ-3 ..39 4410 Month ASQ-3 Information Summary ..4512 Month ASQ-3 ..46 5112 Month ASQ-3 Information Summary ..5214 Month ASQ-3 ..53 5814 Month ASQ-3 Information Summary ..5916 Month ASQ-3 ..60 6516 Month ASQ-3 Information Summary ..6618 Month ASQ-3 ..67 7218 Month ASQ-3 Information Summary ..7320 Month ASQ-3 ..74 7920 Month ASQ-3 Information Summary ..8022 Month ASQ-3 ..81 8622 Month ASQ-3 Information Summary ..8724 Month ASQ-3 ..88 9424 Month ASQ-3 Information Summary ..9527 Month ASQ-3 ..96 10227 Month ASQ-3 Information Summary ..10330 Month ASQ-3 ..104 11030 Month ASQ-3 Information Summary ..11133 Month ASQ-3 ..112 11833 Month ASQ-3 Information Summary ..11936 Month ASQ-3 ..120 12636 Month ASQ-3 Information Summary ..12742 Month ASQ-3 ..128 13442 Month ASQ-3 Information Summary.

6 13548 Month ASQ-3 ..136 14248 Month ASQ-3 Information Summary ..14354 Month ASQ-3 ..144 15054 Month ASQ-3 Information Summary ..15160 Month ASQ-3 ..152 15960 Month ASQ-3 Information Summary ..160 Intervention Activity Sheets ..161 172 Activities for Infants 1 4 Months Old ..162 Activities for Infants 4 8 Months Old ..163 Activities for Infants 8 12 Months Old ..164 Activities for Infants 12 16 Months Old ..165 Activities for Toddlers 16 20 Months Old ..166 Activities for Toddlers 20 24 Months Old ..167 Activities for Children 24 30 Months Old ..168 Activities for Children 30 36 Months Old ..169 Activities for Children 36 48 Months Old ..170 Activities for Children 48 60 Months Old ..171 Activities for Children 60 66 Months Old ..172 What Is ASQ-3 ? (parent handout) ..173 Mailing Sheet ..174 Parent Conference Sheet ..175 Child Monitoring Sheet ..176 About the ASQ-3 ..177 180 About the Authors ..181 183 ASQ Training.

7 184 ASQ Ordering Guide ..185 188 End User License agreement ..189 191 Ages & Stages Questionnaires , Third Edition (ASQ-3 ),Squires & Bricker 2009 Paul H. Brookes Publishing Co. All rights filling out questionnaireBaby s informationDate ASQ completed:Relationship to baby:ParentStreet address:Names of people assisting in questionnaire completion:Grandparent or other relativeGuardianFoster parentTeacherChild care providerOther:PROGRAM INFORMATIONBaby ID #:Program name:Program ID #:Age at administration, in months and days:Ages & StagesQuestionnaires Month Questionnaire1 month 0 days through 2 months 30 daysPlease provide the following information. Use black or blue ink only and printlegibly when completing this s first name:Baby s last name:Baby 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 baby was born 3 or more weeks prematurely, # ofweeks premature:MMD D Y Y Y YBaby s gender:MaleFemaleMiddle initial:Country:MMD D Y Y Y YIf premature, adjusted age, in months and days:MMD DMMD DAges & Stages Questionnaires , Third Edition (ASQ-3 ),Squires & Bricker 2009 Paul H.

8 Brookes Publishing Co. All rights 2 of 5E101020200 Notes:_____Month Questionnaire21 month 0 days through 2 months 30 daysImportant Points to Remember: Try each activity with your baby before marking a response. Make completing this questionnaire a game that is fun foryou and your baby. Make sure your baby is rested and fed. Please return this questionnaire by the following pages are questions about activities babies may do. Your baby may have already done some of the activitiesdescribed here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indi-cates whether your baby is doing the activity regularly, sometimes, or not Does your baby sometimes make throaty or gurgling sounds?2. Does your baby make cooing sounds such as ooo, gah, and aah ?3. When you speak to your baby, does she make sounds back to you?4. Does your baby smile when you talk to him?

9 5. Does your baby chuckle softly?6. After you have been out of sight, does your baby smile or get excitedwhen she sees you?GROSS MOTOR1. While your baby is on his back, does he wave his arms and legs, wiggle,and squirm?2. When your baby is on her tummy, does she turn her head to the side?3. When your baby is on his tummy, does he hold his head up longer thana few seconds?4. When your baby is on her back, does she kick her legs?5. While your baby is on his back, does he move his head from side to side?6. After holding her head up while on her tummy, does your baby lay herhead back down on the floor, rather than let it drop or fall forward?YESSOMETIMESNOT YETCOMMUNICATION TOTALYESSOMETIMESNOT YETGROSS MOTOR TOTALFINE MOTOR1. Is your baby s hand usually tightly closed when he is awake? (If yourbaby used to do this but no longer does, mark yes. )2. Does your baby grasp your finger if you touch the palm of her hand?3. When you put a toy in his hand, does your baby hold it in his hand briefly?

10 4. Does your baby touch her face with her hands?5. Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they were when he was a newborn)?6. Does your baby grab or scratch at her clothes?PROBLEM SOLVING1. Does your baby look at objects that are 8 10 inches away?2. When you move around, does your baby follow you with his eyes?3. When you move a toy slowly from side to side in front of your baby sface (about 10 inches away), does your baby follow the toy with hereyes, sometimes turning her head?4. When you move a small toy up and down slowly in front of your baby sface (about 10 inches away), does your baby follow the toy with his eyes?5. When you hold your baby in a sitting position, does she look at a toy(about the size of a cup or rattle) that you place on the table or floor infront of her?6. When you dangle a toy above your baby while he is lying on his back, does he wave his arms toward the toy?