ASQ-3 48-month 英文

Date ASQ completed:

Parent

Street address:

Names of people assisting in questionnaire completion:

Grandparent

or other

relative

Guardian

Foster

parent

Teacher Child care

provider

Other:

Please provide the following information. Use black or blue ink only and print

legibly when completing this form.

Child’s date of birth:

City:

Home

telephone

number:

State/

Province:

ZIP/

Postal code:

Other

telephone

number:

E-mail address:

Child’s gender:

Male Female

Country:

11/18/2008

11/12/2004

123 Center Street, Apt. 9

Anytown MD 21230

USA 410-555-0155 410-555-01

S

M

page 2 of 7

COMMUNICATION

1.Does your child name at least three items from a common category?

For example, if you say to your child, “Tell me some things that you can

eat,” does your child answer with something like “cookies, eggs, and cereal”? Or if you say, “Tell me the names of some animals,” does your

child answer with something like “cow, dog, and elephant”?2.

Does your child answer the following questions?

(Mark “sometimes” if

your child answers only one question.)

“What do you do when you are hungry?” (Acceptable answers include “get food,” “eat,” “ask for something to eat,” and “have a snack.”)

Please write your child’s response:

“What do you do when you are tired?” (Acceptable answers include “take a nap,” “rest,” “go to sleep,” “go to bed,” “lie down,” and “sit down.”) Please write your child’s response:

3.Does your child tell you at least two things about common objects? For

example, if you say to your child, “Tell me about your ball,” does she say something like, “It’s round. I throw it. It’s big”?4.Does your child use endings of words, such as “-s,” “-ed,” and “-ing”?

For example, does your child say things like, “I see two cat s ,” “I am play ing ,” or “I kick ed the ball”?

YES

SOMETIMES NOT

YET

S Go night-night

510

50

Eat

COMMUNICATION

(continued)

5.Without your giving help by pointing or repeating, does your child fol-low three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child,“Clap your hands, walk to the door, and sit down,” or “Give me the pen, open the book, and stand up.”

6.Does your child use all of the words in a sentence (for example, “a,”

“the,” “am,” “is,” and “are”) to make complete sentences, such as “I am going to the park,” or “Is there a toy to play with?” or “Are you coming, too?”

GROSS MOTOR

1.Does your child catch a large ball with both hands? (You

should stand about 5 feet away and give your child two or three tries before you mark the answer.)

2.Does your child climb the rungs of a ladder of a playground slide and

slide down without help?3.While standing, does your child throw a ball overhand in the

direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)4.Does your child hop up and down on either the right or left foot at

least one time without losing her balance or falling?5.Does your child jump forward a distance of 20 inches from a standing

position, starting with his feet together?

6.Without holding onto anything, does your child stand on

one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)

FINE MOTOR

1.Does your child put together a five- to seven-piece interlocking puzzle?

(If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)

YES

SOMETIMES

NOT YET

COMMUNICATION TOTAL

YES SOMETIMES NOT YET

GROSS MOTOR TOTAL

YES SOMETIMES NOT

YET

S A

M

05

2510101010101060

5

FINE MOTOR

(continued)

2.Using child-safe scissors, does your child cut a paper in

half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.)

3.Using the shapes below to look at, does your child copy at least three

shapes onto a large piece of paper using a pencil, crayon, or pen, with-out tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.)

4.Does your child unbutton one or more buttons?(Your child may use his

own clothing or a doll’s clothing.)5.Does your child draw pictures of people that have at least three of the

following features: head, eyes, nose, mouth, neck, hair, trunk, arms,hands, legs, or feet?6.Does your child color mostly within the lines in a coloring book or

within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4inch outside the lines on most of the picture.)

PROBLEM SOLVING

1.When you say, “Say ‘five eight three,’” does your child repeat just the

three numbers in the same order? Do not repeat the numbers.If neces-sary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers to answer “yes” to this question.)2.When asked, “Which circle is the smallest?” does your child point to

the smallest circle? (Ask this question without providing help by point-ing, gesturing, or looking at the smallest circle.)

3.Without your giving help by pointing, does your child follow three dif-ferent directions using the words “under,” “between,” and “middle”?For example, ask your child to put the shoe “under the couch.” Then ask her to put the ball “between the chairs” and the book “in the middle of the table.”

4.When shown objects and asked, “What color is this?” does your child

name five different colors, like red, blue, yellow, orange, black, white,or pink? (Mark “yes” only if your child answers the question correctly using five colors.)

YES

SOMETIMES

NOT YET

FINE MOTOR TOTAL

YES SOMETIMES NOT

YET

S A

M

105

000

2055

5

PROBLEM SOLVING

(continued)

5.Does your child dress up and “play-act,” pretending to be someone or

something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.6.If you place five objects in front of your child, can he count them by

saying, “one, two, three, four, five,” in order? (Ask this question without providing help by pointing, gesturing, or naming.)

PERSONAL-SOCIAL

1.Does your child serve herself, taking food from one container to an-other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?

2.Does your child tell you at least four of the following? Please mark the

items your child knows.

a. First name d. Last name

b. Age

e. Boy or girl c. City she lives in

f. Telephone number

3.Does your child wash his hands using soap and water and dry off with a

towel without help?4.Does your child tell you the names of two or more playmates, not in-cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)5.Does your child brush her teeth by putting toothpaste on the tooth-brush and brushing all of her teeth without help?(You may still need to check and rebrush your child’s teeth.)6.Does your child dress or undress himself without help (except for

snaps, buttons, and zippers)?

YES

SOMETIMES

NOT YET

PROBLEM SOLVING TOTAL

YES SOMETIMES NOT YET

PERSONAL-SOCIAL TOTAL

OVERALL

Parents and providers may use the space below for additional comments.1.

Do you think your child hears well? If no, explain:

YES

NO

S A

M

50201010

10101010

60

Had severe ear infections. Didn’t start talking until

age 2-3 years, after tubes were placed.

OVERALL

(continued)

2.

Do you think your child talks like other toddlers her age? If no, explain:

3.Can you understand most of what your child says? If no, explain:

4.Can other people understand most of what your child says? If no, explain:

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

If no, explain:

6.Does either parent have a family history of childhood deafness or hearing

impairment? If yes, explain:

7.Do you have any concerns about your child’s vision? If yes, explain:

YES NO

YES

NO

YES NO

YES

NO

YES NO

YES

NO

S A

M P

L

His sentence structure and comprehension are not as advanced as other kids who are a year younger.

Other people have a hard time understanding him.

OVERALL

(continued)

8.

Has your child had any medical problems in the last several months? If yes, explain:

9.Do you have any concerns about your child’s behavior? If yes, explain:

10.Does anything about your child worry you? If yes, explain:

YES NO

YES NO

YES

NO

S A

M P L Language development. No letter or number recognition and he’s 4 years old. Even the 2 1/2 yr old knows more.

Ear infections.

3.

ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP:

You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.

Administering program/provider:

2.TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide,Chapter 6.1.SCORE AND TRANSFER TOTALS TO CHART BELOW:See ASQ-3 User’s Guide for details, including how to adjust scores if item

responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.

4.FOLLOW-UP ACTION TAKEN: __________________________________________s e Y ?

l l e w s r a e H .1NO

Comments:2.

Talks like other toddlers his age?Yes NO Comments:3.Understand most of what your child says?

Yes

NO

Comments:

4.Others understand most of what your child says?Yes

NO

Comments:5.Walks, runs, and climbs like other toddlers?

Yes

NO

Comments: 6.Family history of hearing impairment?

YES No

Comments:7.Concerns about vision?

YES No

Comments:8.Any medical problems?

YES No

Comments:

9.Concerns about behavior?

YES No

Comments:10.Other concerns?

YES No

Comments:

001234567000000

11/12/2004

Ear infex, ear tubes, didn’t talk until 2-3 yrs.Sentences and compreh. not as

advanced as younger kids

Language devel.-doesn’t recognize numbers or letters yet.

Anytown Preschool/Ms. Jenkins

Ear infex