30 Month ASQ

Ages & Stages
Questionnaires®
28 months 16 days through 31 months 15 days
Please provide the following information. Use black or blue ink only and print legibly when completing this form.
Date ASQ completed:
Child’s information
Child’s first name:
Middle initial:
Child’s last name:
Child’s gender:
Male
Female
Child’s date of birth:
Person filling out questionnaire
First name:
Middle initial:
Last name:
Relationship to child:
Parent
Guardian
Teacher
Child care provider
Street address:
Grandparent
Foster
Other:
or other
parent
relative
State/
ZIP/
City:
Province:
Postal code:
Other telephone
Home telephone
Country:
number:
number:
E-mail address:
Names of people assisting in questionnaire completion:
Program Information
Child ID #:
Program ID #:
Program name:
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
P101300100
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
28 months 16 days
Month Questionnaire
30
through 31 months 15 days
On the following pages are questions about activities children may do. Your child may have already done some of the activities
described here, and there may be some your child has not begun doing yet. For each item, please fill in the circle that indicates
whether your child is doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
Notes:
Try each activity with your child before marking a response.
Make completing this questionnaire a game that is fun for
you and your child.
Make sure your child is rested and fed.
Please return this questionnaire by .
COMMUNICATION
YES
SOMETIMES
NOT YET
1. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child,
“What is this?” does your child correctly name at least one picture?
2. Without your giving him clues by pointing or using gestures, can your
child carry out at least three of these kinds of directions?
a. “Put the toy on the table.”
d. “Find your coat.”
b. “Close the door.”
e. “Take my hand.”
c. “Bring me a towel.”
f. “Get your book.”
3. When you ask your child to point to her nose, eyes, hair, feet, ears, and
so forth, does she correctly point to at least seven body parts? (She can
point to parts of herself, you, or a doll. Mark “sometimes” if she cor-
rectly points to at least three different body parts.)
4. Does your child make sentences that are three or four words long?
Please give an example:
5. Without giving your child help by pointing or using gestures, ask him to
“put the book on the table” and “put the shoe under the chair.” Does
your child carry out both of these directions correctly?
6. When looking at a picture book, does your child tell you what is hap-
pening or what action is taking place in the picture (for example, “bark-
ing,” “running,” “eating,” or “crying”)? You may ask, “What is the dog
(or boy) doing?”
COMMUNICATION TOTAL
page 2 of 7
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101300200
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
30 Month Questionnaire page 3 of 7
GROSS MOTOR
YES
SOMETIMES
NOT YET
1. Does your child run fairly well, stopping herself without
bumping into things or falling?
2. Does your child walk either up or down at least two steps
by himself? He may hold onto the railing or wall. (You can
look for this at a store, on a playground, or at home.)
3. Without holding onto anything for support, does your child
kick a ball by swinging his leg forward?
4. Does your child jump with both feet leaving the floor at the
same time?
5. Does your child walk up stairs, using only one foot on each
*
stair? (The left foot is on one step, and the right foot is on
the next.) She may hold onto the railing or wall.
6. Does your child stand on one foot for about 1 second
without holding onto anything?
GROSS MOTOR TOTAL
*If Gross Motor Item 5 is marked
“yes” or “sometimes,” mark
Gross Motor Item 2 “yes.”
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101300300
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
30 Month Questionnaire page 4 of 7
FINE MOTOR
YES
SOMETIMES
NOT YET
1. Does your child use a turning motion with her hand while trying to turn
doorknobs, wind up toys, twist tops, or screw lids on and off jars?
Count as “yes”
2. After your child watches you draw a line from the top of
the paper to the bottom with a pencil, crayon, or pen, ask
him to make a line like yours. Do not let your child trace
your line. Does your child copy you by drawing a single
Count as “not yet”
line in a vertical direction?
3. Can your child string small items such as beads,
macaroni, or pasta “wagon wheels” onto a string
or shoelace?
Count as “yes”
4. After your child watches you draw a line from one
side of the paper to the other side, ask her to make
a line like yours. Do not let your child trace your
Count as “not yet”
line. Does your child copy you by drawing a single
line in a horizontal direction?
Count as “yes”
5. After your child watches you draw a single circle, ask
him to make a circle like yours. Do not let him trace
your circle. Does your child copy you by drawing a
Count as “not yet”
circle?
6. Does your child turn pages in a book, one page at a time?
FINE MOTOR TOTAL
PROBLEM SOLVING
YES
SOMETIMES
NOT YET
1. When looking in the mirror, ask, “Where is _______?”
(Use your child’s name.) Does your child point to her
image in the mirror?
2. If your child wants something he cannot reach, does he find a chair or
box to stand on to reach it (for example, to get a toy on a counter or to
“help” you in the kitchen)?
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101300400
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
30 Month Questionnaire page 5 of 7
PROBLEM SOLVING
(continued)
YES
SOMETIMES
NOT YET
3. While your child watches, line up four objects like
blocks or cars in a row. Does your child copy or
imitate you and line up four objects in a row?
(You can also use spools of thread, small boxes, or
other toys.)
4. When you point to the figure and ask your child, “What is
this?” does your child say a word that means a person or
something similar? (Mark “yes” for responses like “snowman,”
“boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”)
Please write your child’s response here:
5. When you say, “Say ‘seven three,’” does your child repeat just the two
numbers in the same order? Do not repeat the numbers. If necessary,
try another pair of numbers and say, “Say ‘eight two.’” Your child must
repeat just one series of two numbers for you to answer “yes” to this
question.
6. After your child draws a “picture,” even a simple scribble, does she tell
you what she drew? (You may say, “Tell me about your picture,” or ask,
“What is this?” to prompt her.)
PROBLEM SOLVING TOTAL
PERSONAL-SOCIAL
YES
SOMETIMES
NOT YET
1. If you do any of the following gestures, does your child copy at least
one of them?
a. Open and close your mouth.
c. Pull on your earlobe.
b. Blink your eyes.
d. Pat your cheek.
2. Does your child use a spoon to feed himself with little spilling?
3. Does your child push a little wagon, stroller, or other toy on wheels,
steering it around objects and backing out of corners if she cannot
turn?
4. Does your child put on a coat, jacket, or shirt by himself?
5. After you put on loose-fitting pants around her feet, does your child
pull them completely up to her waist?
6. When your child is looking in a mirror and you ask, “Who is in the mir-
ror?” does he say either “me” or his own name?
PERSONAL-SOCIAL TOTAL
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101300500
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
30 Month Questionnaire page 6 of 7
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
2. Do you think your child talks like other toddlers her age? If no, explain:
YES
NO
3. Can you understand most of what your child says? If no, explain:
YES
NO
4. Can other people understand most of what your child says? If no, explain:
YES
NO
5. Do you think your child walks, runs, and climbs like other toddlers his age?
YES
NO
If no, explain:
6. Does either parent have a family history of childhood deafness or hearing
YES
NO
impairment? If yes, explain:
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101300600
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
30 Month Questionnaire page 7 of 7
OVERALL
(continued)
7. Do you have any concerns about your child’s vision? If yes, explain:
YES
NO
8. Has your child had any medical problems in the last several months? If yes, explain:
YES
NO
9. Do you have any concerns about your child’s behavior? If yes, explain:
YES
NO
10. Does anything about your child worry you? If yes, explain:
YES
NO
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101300700
© 2009 Paul H. Brookes Publishing Co. All rights reserved.