Ages Stages 18 Month Form PDF Details

The Ages & Stages Questionnaires 18 Month (ASQ-3) form screens children aged 17 months 0 days to 18 months 30 days. Fill it out using black or blue ink. Start by recording the child's name, gender, date of birth, and whether the child was born prematurely.

What the Form Covers

The questionnaire assesses five developmental areas: communication, gross motor, fine motor, problem-solving, and personal-social skills. Each section contains targeted questions to observe and record age-specific abilities. Try each activity with the child before recording an answer for the most accurate results.

Scoring and Next Steps

The final section asks about hearing, speech, physical abilities, and family medical history. Bring the completed form to your child's next pediatric visit. For related tools, see the ASQ 14-month questionnaire, the ASQ-3 questionnaire, and the ASQ 54-month questionnaire.

QuestionAnswer
Form NameAges Stages 18 Month Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other names18month asq, ages stages 18 questionnaires, ages stages 18 month pdf, printable asq forms

Form Preview Example

Ages & Stages

Questionnaires®

18 17 months 0 days through 18 months 30 days

Month Questionnaire

Please provide the following information. Use black or blue ink only and print legibly when completing this form.

Date ASQ completed:

Child’s information

 

Middle

 

 

 

 

 

Child’s first name:

initial:

Child’s last name:

 

 

 

 

 

If child was born 3

Child’s gender:

 

 

 

 

or more weeks

Male

Female

 

 

 

prematurely, # of

 

 

 

 

 

Child’s date of birth:

 

 

weeks premature:

 

 

 

 

Person filling out questionnaire

 

Middle

Last name:

 

 

 

First name:

initial:

 

 

 

 

 

Relationship to child:

 

 

 

 

 

Parent

Guardian

Teacher

Child care

 

 

provider

 

 

 

 

 

Street address:

 

Grandparent

Foster

Other:

 

 

 

or other

parent

 

 

 

 

 

 

 

relative

 

 

 

 

State/

ZIP/

City:

Province:

Postal code:

 

 

 

 

Home

Other

 

telephone

telephone

Country:

number:

number:

 

 

 

E-mail address:

 

 

 

 

 

Names of people assisting in questionnaire completion:

 

 

 

 

 

 

 

 

Program Information

 

Child ID #:

Age at administration in months and days:

 

 

 

 

 

 

Program ID #:

If premature, adjusted age in months and days:

 

 

 

 

 

 

Program name:

 

 

 

 

 

 

 

 

 

 

P101180100

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

 

© 2009 Paul H. Brookes Publishing Co. All rights reserved.

 

18 Month Questionnaire

17 months 0 days

through 18 months 30 days

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described 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 yet.

Important Points to Remember:

✓

❑ Try each activity with your baby 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 _______________.

Notes:

____________________________________________

____________________________________________

____________________________________________

____________________________________________

At this age, many toddlers may not 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

YES

SOMETIMES

NOT YET

1. When your child wants something, does she tell you by pointing to it?

2. When you ask your child to, does he go into another room to find a fa- 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 addition to “Mama” and “Dada”?

4. Does your child imitate a two-word sentence? For example, when you 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 when you say, “Show me the kitty,” or ask, “Where is the dog?” (He needs to identify only one picture correctly.)

6. Does your child say two or three words that represent different ideas together, such as “See dog,” “Mommy come home,” or “Kitty gone”?

(Don’t count word combinations that express one idea, such as “bye- bye,” “all gone,” “all right,” and “What’s that?”) Please give an ex-

ample of your child’s word combinations:

COMMUNICATION TOTAL

page 2 of 6

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Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

© 2009 Paul H. Brookes Publishing Co. All rights reserved.

18 Month Questionnaire page 3 of 6

GROSS MOTOR

YES

SOMETIMES

NOT YET

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 walk well and seldom fall?

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 railing 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 it? (If your child already kicks a ball, mark “yes” for this item.)

GROSS MOTOR TOTAL

FINE MOTOR

YES

SOMETIMES

NOT YET

1. Does your child throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)

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

of a crayon (or pencil or pen) when trying to draw?

4. Does your child stack three small blocks or toys on top of each other by himself?

5. Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)

6. Does your child get a spoon into her mouth right side up so that the food usually doesn’t spill?

FINE MOTOR TOTAL

E101180300

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

© 2009 Paul H. Brookes Publishing Co. All rights reserved.

18 Month Questionnaire page 4 of 6

PROBLEM SOLVING

YES

SOMETIMES

NOT YET

1. Does your child drop several small toys, one after another, into a con- tainer like a bowl or box? (You may show him how to do it.)

2. After you have shown your child how, does she try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?

3. After a crumb or Cheerio is dropped into a small, clear bottle, does your child turn the bottle over to dump it out? (You may show him how.) (You can use a soda-pop bottle or a baby bottle.)

4. Without your showing her how, does your child scribble back and forth when you give her a crayon (or pencil or pen)?

Count as “yes”

5. After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on

the paper in any direction? (Mark “not yet” if your Count as “not yet” child scribbles back and forth.)

6. After a crumb or Cheerio is dropped into a small, clear bottle, does

 

*

your child turn the bottle upside down to dump out the crumb or

 

 

Cheerio? (Do not show him how.)

 

 

PERSONAL-SOCIAL

1.While looking at herself in the mirror, does your child offer a toy to her own image?

2.Does 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?

4.Does your child come to you when he needs help, such as with winding up a toy or unscrewing a lid from a jar?

5.Does your child drink from a cup or glass, putting it down again with little spilling?

6.Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair?

PROBLEM SOLVING TOTAL

*If Problem Solving Item 6 is marked “yes” or “sometimes,” mark Problem Solving Item 3 “yes.”

YES

SOMETIMES

NOT YET

PERSONAL-SOCIAL TOTAL

E101180400

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

© 2009 Paul H. Brookes Publishing Co. All rights reserved.

18 Month Questionnaire page 5 of 6

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 his age? If no, explain:

YES

NO

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

YES

NO

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

YES

NO

If no, explain:

 

 

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

YES

NO

impairment? If yes, explain:

 

 

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

YES

NO

E101180500

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

© 2009 Paul H. Brookes Publishing Co. All rights reserved.

18 Month Questionnaire page 6 of 6

OVERALL (continued)

 

 

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

YES

NO

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

YES

NO

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

YES

NO

E101180600

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker

© 2009 Paul H. Brookes Publishing Co. All rights reserved.

How to Edit Ages Stages 18 Month Form Online for Free

Use FormsPal to fill in or edit the 18 month ASQ questionnaire online. Follow these steps to complete the ages stages 18 month form quickly.

Step 1: Click the "Get Form" button at the top of this page to open the PDF editor.

How you can fill out 18 month questionnaire asq stage 1

Step 2: Fill in the child's basic information: Country, Email address, Child ID, Program ID, Program name, Home telephone number, Other telephone number, age at administration in months, and whether the child was born prematurely.

Child ID, If premature adjusted age in, and Other telephone number inside 18 month questionnaire asq

Step 3: Work through the developmental sections. Answer YES, SOMETIMES, or NOT YET for each activity. Try each activity with your child before responding. The form covers five skill areas: communication, gross motor, fine motor, problem-solving, and personal-social development.

SOMETIMES, NOT YET, and At this age many toddlers may not inside 18 month questionnaire asq

Step 4: Complete the Communication section. This section asks whether your child says eight or more words, imitates two-word phrases, and responds to simple instructions like "Show me the kitty."

Does your child say two or three words together and Does your child imitate a two-word phrase inside 18 month questionnaire asq

Step 5: Finish the Gross Motor and Fine Motor sections. These ask whether your child walks well, bends and stands without help, climbs on objects to reach a toy, and walks down stairs with assistance.

Filling out part 5 of 18 month questionnaire asq

Step 6: Review your answers, then click "Done." Download, email, or save the completed form to your FormsPal account.

Looking for other age-range forms? The ASQ 14-month questionnaire covers younger children, while the child and adolescent health form covers older age groups.

Ages Stages 18 Month Form isn’t the one you’re looking for?

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