Child’s information Luke K Jones SAMPLE

1 Ages & Stages Questionnaires : Social-Emotional, Second Edition (ASQ:SE-2 ), Squires, Bricker, & Twombly. 2015 Paul H. Brookes Publishing Co., Inc. All rights EDITION2 Child care provider Foster parent Grandparent/other relative Other: Teacher Guardian ParentRelationship to child:People assisting in questionnaire completion:Program information (For program use only.)Child s ID #:Age at administration in months and days:Program ID #:Program name:E- mail address:Other telephone number:Home telephone number:Country:ZIP/postal code:State/province:City:Street address:Last name:Middle initial:First name:24 MonthQuestionnaire21 months 0 days through 26 months 30 daysDate ASQ:SE- 2 completed: _____Child s informationChild s fi rst name:Child s middle initial:Child s last name:Child s date of birth:Child s gender.

2 Male FemalePerson fi lling out questionnaire3/30/15 LukeKJones2/23/13 LucyKJones20 First States1323545767989138425 months, 7 days243465687819213 Charm City Child CareSAMPLEAges & Stages Questionnaires : Social-Emotional, Second Edition (ASQ:SE-2 ), Squires, Bricker, & Twombly. 2015 Paul H. Brookes Publishing Co., Inc. All rights 1 of 52 Please return this questionnaire by: _____ If you have any questions or concerns about your child orabout this questionnaire, contact: _____ Thank you and please look forward to filling out anotherASQ:SE- 2 in _____ months.

3 Caregivers who know the child well and spend more than15 20 hours per week with the child should complete ASQ:SE- 2. Answer questions based on what you know about yourchild s behavior. Answer questions based on your child s usual behavior,not behavior when your child is sick, very tired, or month QUESTIONNAIRE 21 months 0 days through 26 months 30 daysQuestions about behaviors children may have are listed on the following pages. Please read each question carefully and check the box that best describes your child s behavior. Also, check the circle if the behavior is a Points to Remember:OfTEN OR AlwAySSOME-TIMESRAREly OR NEvERChECk If ThIS IS A your child look at you when you talk to him?

4 Z v x your child seem too friendly with strangers? x v z your child laugh or smile when you play with her? z v x your child s body relaxed? z v x you leave, does your child stay upset and cry formore than an hour? x v z your child greet or say hello to familiar adults? z v x your child like to be hugged or cuddled? z v x upset, can your child calm down within 15 minutes? z v x v_____TOTAL POINTS ON PAGE _____10___500000015 z zSAMPLEAges & Stages Questionnaires : Social-Emotional, Second Edition (ASQ:SE-2 ), Squires, Bricker, & Twombly.

5 2015 Paul H. Brookes Publishing Co., Inc. All rights 2 of 5224 month QuestionnaireCheck the box that best describes your child s behavior. Also, check the circle if the behavior is a OR AlwAySSOME-TIMESRAREly OR NEvERChECk If ThIS IS A your child stiffen and arch his back when picked up? x v z v_____ your child interested in things around her,such as people, toys, and foods? z v x v_____ your child cry, scream, or have tantrums for long periodsof time? x v z v_____ you and your child enjoy mealtimes together? z v x v_____ your child have eating problems?

6 For example, does hestuff food, vomit, eat things that are not food, or _____?(Please describe.) _____ _____ x v z v_____ your child sleep at least 10 hours in a 24- hour period? z v x v_____ you point at something, does your child look in thedirection you are pointing? z v x v_____ your child have trouble falling asleep at naptime or at night? x v z v_____ your child get constipated or have diarrhea? x v z v_____TOTAL POINTS ON PAGE _____5500000000 SAMPLEAges & Stages Questionnaires : Social-Emotional, Second Edition (ASQ:SE-2 ), Squires, Bricker, & Twombly.

7 2015 Paul H. Brookes Publishing Co., Inc. All rights 3 of 5224 month QuestionnaireCheck the box that best describes your child s behavior. Also, check the circle if the behavior is a OR AlwAySSOME-TIMESRAREly OR NEvERChECk If ThIS IS A CONCERN your child follow simple directions? For example, doesshe sit down when asked? z v x v_____ your child let you know how he is feeling with wordsor gestures? For example, does he let you know when he ishungry, hurt, or tired? z v x v_____ your child check to make sure you are near whenexploring new places, such as a park or a friend s home?

8 Z v x v_____ your child do things over and over and get upset whenyou try to stop her? For example, does she rock, flap her hands,spin, or _____? (Please describe.) _____ _____ x v z v_____ your child like to hear stories or sing songs? z v x v_____ your child hurt himself on purpose? x v z v_____ your child like to be around other children?For example, does she move close to or look atother children? z v x v_____ your child try to hurt other children, adults, or animals(for example, by kicking or biting)? x v z v_____ your child try to show you things by pointing at themand looking back at you?

9 Z v x v_____TOTAL POINTS ON PAGE _____5500000000 zSAMPLEAges & Stages Questionnaires : Social-Emotional, Second Edition (ASQ:SE-2 ), Squires, Bricker, & Twombly. 2015 Paul H. Brookes Publishing Co., Inc. All rights 4 of 5224 month QuestionnaireCheck the box that best describes your child s behavior. Also, check the circle if the behavior is a OR AlwAySSOME-TIMESRAREly OR NEvERChECk If ThIS IS A CONCERN your child play with objects by pretending? For example,does your child pretend to talk on the phone, feed a doll, or fly atoy airplane? z v x v_____ your child wake three or more times during the night?

10 X v z v_____ your child respond to his name when you call him? Forexample, does he turn his head and look at you? z v x v_____ your child too worried or fearful? If sometimes or often oralways, please describe: _____ _____ _____ x v z v_____ anyone shared concerns about your child s behaviors? If sometimes or often or always, please explain: _____ _____ _____ x v z v_____TOTAL POINTS ON PAGE _____Luke is hesitant when he is in unfamiliarplaces and day care provider say it takes Lukea while to stop crying when we & Stages Questionnaires : Social-Emotional, Second Edition (ASQ:SE-2 ), Squires, Bricker, & Twombly.