Ages & Stages * Questionnaires” £7 months O cys rough 18 months 30 dos 1 8 Month Questionnaire Pee ai a hg ron kbc Date ASO compte Child's information Mite Person filling out questionnaire ee set a e O euro © renter ©) proc 2 OSs" OF Oot * eis, Country urber number Program Information Program nam Ages & Stages Quesionnites®, The Edtion(ASCS), Suites & Becher 101180100 {012009 Paul Srockes Pushing Co. Alright reserved18 Month Questionnaire youn feces On the following pages are questions about activites 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 il in the circle thet indicates ‘whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: Notes: | | & Tryeach activity with your ehild before marking a response. | Make completing this questionnaire 2 game that is fun for you and your chil. g Make sure your childs rested and fed a Please return this questionnaire by Ac this age, many taddlers may nat be cooperative when asked to do things. You may need to try the following activities with your child more than one time. If possible, try the activities when your child is cooperative. If your child can do the activity but refuses, ‘mark "yes" for the item COMMUNICATION we SOMETIMES —_NOTYET 1. When your child wants something, does she tll you by pointing to it? °O S) o — 2. When you ask your child to, does he go into another room to find a far Oo Oo o — miliar toy or object? (You might ask, "Where is your ball?” or say, “Bring me your coat," or "Go get your blanket.") 3. Does your child say eight or more words in adklition to "Mama" and Oo Oo o ~~ "Dada"? 4. Does your child imitate a two-word sentence? Far example, when you oO Oo Oo. . = say a two-word phrase, such as "Mama eat," "Daddy play,” “Go home," or "What's this?” does your child say both words back to you? (Mark “yes” even if her words are difficult to understand.) 5. Without your showing him, does your child point to the correct picture Oo ° O° when you say, "Show me the kitty" of ack, “Where i the dog?” (He needs to identily only one picture correct.) 4, Does your child say two or three wards that represent different idess oO oO Oo together, such as "See dag,” "Mommy come home,” of “Kity gone”? {Don't count word combinations that express one idea, such as "bye- bye," “all gone,” “allright,” and “What's tha?") Please give an ex- ample of your child's word combinations COMMUNICATION TOTAL = page 208 Ages & Siagos uesSonnsrs®, This Editon (450.3%, Squies & Bicker 101180200 9008S BSoN Poa BeaskesPlehing Coal ight rene.18 Month Questionnaire page 3016 BASQS GROSS MOTOR ves SOweTMES —_NOTYET Oo Oo — 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 her hands and knees? 3. Does your child wall well and seldom fall? 0000 00 0 00 0 | 4. Does your child climb on an object such as a chair to reach something he wants (for example, to get a toy on a counter or to “help” you in the kitchen)? 5, Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the raiting or wall. (You can look for this at a store, on a playground, or at home.) ° ° ° | 6. When you show your child how to kick a large ball, does he try — to kick the ball by moving his leg forward or by walking into * ° 2 ° it? (Ff your child already kicks a ball, mark "yes" for this item.) GROSS MOTORTOTAL = FINE MOTOR ves SOMETIMES, NOT YET 1. Boes your child throw a small ball with a forward sem motion? (fhe simply drops the bal, mark “nat yet” fr this tem) Oo oO Oo —_ 2, Does your child stack a small block or toy on top of another one? (You could also use spools of thread, small boxes, or toys that are about 1 ° ° ° inch in size.) 3. Does your child make a mark on the paper with the tip ei tetmalarpn merase FS i. 2 oo 4. Does your child stack three small locks or toys ontop of each otherby Oo o ~— timsell? 5. Does your child turn the pages of a book by himself? (He may tum Oo Oo o ~— ‘more than one page at a time.) 6. Does your child get a spoon inte her mouth right side up so that the oO Oo © food usually doesnt spl? FINE MOTOR TOTAL = ‘Ages & Stogas Questionnates®, Third Edvion(ASO-3™), Sis & Bricker 101180300 152009 Paul. Brookes Pubhing Co, Aight resoretASQ) 18 Month Questionnaire page sofé PROBLEM SOLVING ves SOMETIMES NoTvET 1. Does your child drop several small toys, one after another, into a can- oO O O tainer like a bowl or box? (You may show him how to doit) 2. Alter you have shown your child how, does she ty to get ‘a small toy that is slightly out of reach by using @ spoon, stick, or similar tool? oa oO O° oO — 3. After crumb or Cheerios dropped into a smal, clear botle, does Oo ° o — your child tum the bottie over to dump it out? (You may show him how) (You can use» sode-pop bottle or a baby bottle) 4, Without your showing her how, does your child scribble back and forth Oo O shen you give her a crayon (or pencil or pen? ° | 5. After watching you draw a line from the top of the BIN Oo Oo O° = paper to the bottom with a erayon (er pencil or per], << does your child copy you by drawing a single line on the paper in any direction? (Mark “not yet” ifyour Count at “ety child scribbles back and forth.) aC 6. After a crumb or Cheer is dropped into a small clear bottle, does, your child turn the bottle upside down to dump out the crumb or Cheetio? (Do not show him how) O° Oo PROBLEM SOLVING TOTAL = __. “18 Problem Solving Iter 6 is PERSONAL-SOCIAL ves, SOMETIMES, Novver Oo ° a 1. While looking at herself in the mirror, does your child offer a toy to her ‘own image? oes your child play with a doll or stuffed animal by hugging it? 3, Does your child get your attention or try to show you something by pulling on your hand or clothes? ° oO 4, Does your child come to you when he needs help, such as with winding Oo upa toy or unscrewing lid from a jar? 5. Does your child drink from a cup or glass putting it down again with O° litle spilling? O0o0o00 00 0 & Does your child copy the activities you do, such as wipe up a spil, sweep, shave, or comb hair? ° ° | PERSONALSOCIALTOTAL = __ ‘Ages & Stages Questionnaes®, Tid Eon ASO-3H), Squies & Bicker E101180400 (012009 Paul Brookes Publishing Co. Aight vesorvedBASQ3) 18 Month Questionnaire page sors OVERALL Parents and providers may use the space below for additional comments. 1. Do you think your child hears well? if no, explain: Ons Ono __ \ 2. Do you thnk your chill talks ke other toddlers hs age? IFno, explain Ont Oe 3. Can you understand most of what your cid 9) IF no, explain Orr | Om 4, Do you think your child walks, runs, and climbs like other toddlers her age? Ons Ono Ire explain 5. Does either parent have a family history of childhood deainess or hearing Ons Ono impairment? if yes, explain: 6, Do,you have concerns about your chills sion? yes, explain Ow Ow ‘Ages & Stages Questionnsves®, Third Edtion ASO.3), Sais & Backer E101180500 {012009 Pau H Brooker Publishing Co lights resarvedBASQ3 18 Month Questionnaire page é 0/6 OVERALL ccoinecs 7. Has your child had any medical problems in the last several months? If yes, explain: Ow Ono ~ 8. Do you have any concems about your child's behavior? If yes, explain Ove Ono 9. Does anything about your child worry you? If yes, explain: Ons Ow E101180600 A008 8 BaP Noles Rokbiog Co soiigneresred(a ASQ3 18 Month ASQ-3 Information Summary 172s Oceys though Chile's name: Date ASQ completed Chile's 1D _ Date of birth —_ — Administering program/provider: Was age adjusted for prematurity when selecting questionnaire? (©) Yes ©) No 1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASO-3 User's Guide for details, including how to adjust scores ifitem 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, ares | curott | score |_0 HO 19 820/25 0et 90 es 240) ASE SOL iss ‘Communication| Grose Mater Fine Motor Problem Saving £0 O_O] QO. 0 23 Oo 2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User's Guide, Chapter 6, 1. Hears well? Yes NO & Concerns about vision? YES No Comments: Comments: 2. Talks like other toddlers his age? Yes NO 7. Anymedical problems? YES No Comments: Comments: 3. Understand most of what your child says? Yes NO 8. Concerns about behavior? YES No Comments: Comments: 4. Walks, runs, and climbs like other toddlers? —-Yes_:« NO 9. Other concerns? YES No Comments: Comments: 5. Family history of hearing impairment? YES No Comments: 3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must cansider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up. Uf the child's total score is in the (=I area, itis above the cutoff, and the child's development appears to be on schedule. Ifthe child's total score is in the GI area, iti close to the cutoff. Provide learning activities and monitor. ifthe child's total score is in the alll area, itis below the cutoff, Further assessment with a professional may be needed. 4. FOLLOW-UP ACTION TAKEN: Check all that apply. 5. OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X= response missing). Provide activities and rescreen in___ months. __ Share results with primary health care provider. primary P 1[2[3[4[s[o __. Refer for (circle all that apply) hearing, vision, and/or behavioral screening. A - Refer to primary health care provider or other community agency (specify “Grea Motor Refer to early intervention/early childhood special education pees No further action taken at this time —— (Other (specify: Ages Sages Questions Thd Eon 150-1, Sirs 8 Bicker 101180700 {Bids Pel Becher Pblahing Co. Allighsvesored