Asq 3 14 Months Details

As parents, we want to ensure that our children are meeting key developmental milestones. The American Academy of Pediatrics (AAP) has created a questionnaire to help parents track their child's development during the first 14 months of life. The Asq 14 Month Questionnaire can be used to monitor your child's progress in five major categories: physical development, language skills, problem solving abilities, social-emotional skills, and curiosity and exploratory behavior. By tracking your child's progress with this questionnaire, you can identify any potential delays and seek assistance from a healthcare provider if necessary.

Below, you'll find a number of details about asq 14 month questionnaire PDF. There, you'll get the information about the form you intend to fill out, including the estimated time for you to fill it out and also other data.

QuestionAnswer
Form NameAsq 14 Month Questionnaire
Form Length7 pages
Fillable?Yes
Fillable fields219
Avg. time to fill out22 min 48 sec
Other namesasq 14 month, asq 3 14 months, asq 3 14 month questionnaire, 14 mo asq

Form Preview Example

Ages & Stages

Questionnaires®

14 13 months 0 days through 14 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:

Baby’s information

 

Middle

 

 

 

 

 

Baby’s first name:

initial:

Baby’s last name:

 

 

 

 

 

If baby was born 3

Baby’s gender:

 

 

 

 

or more weeks

Male

Female

 

 

 

prematurely, # of

 

 

 

 

 

Baby’s date of birth:

 

 

weeks premature:

 

 

 

 

Person filling out questionnaire

 

Middle

Last name:

 

 

 

First name:

initial:

 

 

 

 

 

Relationship to baby:

 

 

 

 

 

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

 

Baby ID #:

Age at administration in months and days:

 

 

 

 

 

 

Program ID #:

If premature, adjusted age in months and days:

 

 

 

 

 

 

Program name:

 

 

 

 

 

 

 

 

 

 

P101140100

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

 

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

 

14 Month Questionnaire

13 months 0 days through 14 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 baby.

Make sure your baby 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 baby more than one time. If possible, try the activities when your baby is cooperative. If your baby can do the activity but refuses, mark “yes” for the item.

COMMUNICATION

YES

SOMETIMES

NOT YET

1. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)

2. When your baby wants something, does she tell you by pointing to it?

3. Does your baby shake his head when he means “no” or “yes”?

4. Does your baby point to, pat, or try to pick up pictures in a book?

5. Does your baby say four or more words in addition to “Mama” and “Dada”?

6. When you ask her to, does your baby 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.”)

COMMUNICATION TOTAL

GROSS MOTOR

YES

SOMETIMES

NOT YET

1. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark “yes” for this item.)

2. When you hold one hand just to balance her, does your baby take several steps forward? (If your baby already walks alone, mark “yes” for this item.)

page 2 of 6

E101140200

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

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

14 Month Questionnaire page 3 of 6

GROSS MOTOR (continued)

YES

SOMETIMESNOT YET

3. Does your baby stand up in the middle of the floor by himself and take several steps forward?

4. Does your baby climb onto furniture or other large objects, such as large climbing blocks?

5. Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?

6. Does your baby move around by walking, rather than by crawling on his hands and knees?

GROSS MOTOR TOTAL

FINE MOTOR

YES

SOMETIMES

NOT YET

1. Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?

2. Does your baby throw a small ball with a forward arm mo- tion? (If he simply drops the ball, mark “not yet” for this item.)

3. Does your baby help turn the pages of a book? (You may lift a page for her to grasp.)

4. Does your baby 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.)

5. Does your baby make a mark on the paper with the tip

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

6. Does your baby stack three small blocks or toys on top of each other by herself?

FINE MOTOR TOTAL

E101140300

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

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

14 Month Questionnaire page 4 of 6

PROBLEM SOLVING

YES

SOMETIMES

NOT YET

1.If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although he may not let go of it? (If he already lets go of the toy into a bowl or box, mark “yes” for this item.)

2.Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show

her how to do it.)

3.After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If he already scribbles on his own, mark “yes” for this item.)

4.Can your baby drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?

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

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

*

PROBLEM SOLVING TOTAL

*If Problem Solving Item 2 is marked “yes” or “sometimes,” mark Problem Solving Item 1 as “yes.”

PERSONAL-SOCIAL

YES

SOMETIMES

NOT YET

1. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?

2. Does your baby roll or throw a ball back to you so that you can return it to him?

3. Does your baby play with a doll or stuffed animal by hugging it?

4. Does your baby feed herself with a spoon, even though she may spill some food?

5. Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?

6. Does your baby get your attention or try to show you something by pulling on your hand or clothes?

PERSONAL-SOCIAL TOTAL

E101140400

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

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

14 Month Questionnaire page 5 of 6

OVERALL

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

1. Does your baby use both hands and both legs equally well? If no, explain:

YES

NO

2. Does your baby play with sounds or seem to make words? If no, explain:

YES

NO

3. When your baby is standing, are her feet flat on the surface most of the time?

YES

NO

If no, explain:

 

 

4. Do you have concerns that your baby is too quiet or does not make sounds like

YES

NO

other babies do? If yes, explain:

 

 

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

YES

NO

impairment? If yes, explain:

 

 

E101140500

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

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

14 Month Questionnaire page 6 of 6

OVERALL (continued)

 

 

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

YES

NO

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

YES

NO

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

YES

NO

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

YES

NO

E101140600

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

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

14 Month ASQ-3 Information Summary

13 months 0 days through

14 months 30 days

Baby’s name: ______________________________________________________

Baby’s ID #: ______________________________________________________

Administering program/provider:

Date ASQ completed: __________________________________________

Date of birth: ______________________________________________

Was age adjusted for prematurity

 

 

when selecting questionnaire?

Yes

No

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.

 

Total

0

5

10

15

20

25

30

35

40

45

50

55

60

Area

Cutoff Score

Communication

17.40

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Motor

25.80

 

 

 

 

 

 

 

 

 

 

 

 

 

Fine Motor

23.06

 

 

 

 

 

 

 

 

 

 

 

 

 

Problem Solving

22.56

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal-Social

23.18

 

 

 

 

 

 

 

 

 

 

 

 

 

2.TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.

1.

Uses both hands and both legs equally well?

Yes

NO

6.

Concerns about vision?

YES

No

 

Comments:

 

 

 

Comments:

 

 

2.

Plays with sounds or seems to make words?

Yes

NO

7.

Any medical problems?

YES

No

 

Comments:

 

 

 

Comments:

 

 

3.

Feet are flat on the surface most of the time?

Yes

NO

8.

Concerns about behavior?

YES

No

 

Comments:

 

 

 

Comments:

 

 

4.

Concerns about not making sounds?

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

If the baby’s total score is in the If the baby’s total score is in the If the baby’s total score is in the

area, it is above the cutoff, and the baby’s development appears to be on schedule.

area, it is close to the cutoff. Provide learning activities and monitor.

area, it is below the cutoff. Further assessment with a professional may be needed.

4. FOLLOW-UP ACTION TAKEN: Check all that apply.

______

Provide activities and rescreen in _____ months.

______

Share results with primary health care provider.

______

Refer for (circle all that apply) hearing, vision, and/or behavioral screening.

______

Refer to primary health care provider or other community agency (specify

 

reason): __________________________________________________________.

______

Refer to early intervention/early childhood special education.

______

No further action taken at this time

______

Other (specify): ____________________________________________________

5.OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X = response missing).

1

2

3

4

5

6

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

P101140700

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

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

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