Ages & Stages 30 month

Ages & Stages
Questionnaires
28 months 16 days through 31 months 15 days 30Month Questionnaire
Please provide the following information. Use black or blue ink only and print legibly when completing this form.
Date ASQ completed:

MonthDayYear
Date
Child's full name:
Child's Date of Birth:
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 answer that indicates 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 questionnarie a game that is fun for you and your child.

Make sure your child is rested and fed.
COMMUNICATION
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?

YesSometimesNot yet
Calculation
Without your giving your child clues by pointing or using gestures, can your child carry out at least three of these kinds of directions? Please answer each question below
"Put the toy on the table."

YesSometimesNot yet
Calculation
"Close the door."

YesSometimesNot yet
Calculation
"Bring me a towel."

YesSometimesNot yet
Calculation
"Find your coat."

YesSometimesNot yet
Calculation
"Take my hand."

YesSometimesNot yet
Calculation
"Get your book."

YesSometimesNot yet
Calculation
When you ask your child to point to their nose, eyes, hair, feet, ears, and so forth, does your child correctly point to at least seen body parts? (They can point to parts of him/herself, you, or a doll. Mark "sometimes" if they correctly point to at least three different body parts.)

YesSometimesNot yet
Calculation
Does your child make sentences that are three or four words long? Please give an example.
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?

YesSometimesNot yet
Calculation
When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, "barking," "running," "eating," or "crying")? You may ask, "What is the dog (or boy) doing?"

YesSometimesNot yet
Calculation
Communication Total
Calculation
GROSS MOTOR
Does your child run fairly well, stopping herself without bumping into things or falling?

YesSometimesNot yet
Calculation
Does your child walk either up or down at least two steps by himself? He may hold onto th railing or wall. (You can look for this at a store, on a playground, or at home.)

YesSometimesNot yet
Calculation
Without holding onto anything for support, does your child kick a ball by swinging their leg forward?

YesSometimesNot yet
Calculation
Does your child jump with both feet leaving the floor at the same time?

YesSometimesNot yet
Calculation
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.) He/she may hold onto the railing or wall.

YesSometimesNot yet
Calculation
Does your child stand on one foot for about 1 second without holding onto anything?

YesSometimesNot yet
Calculation
Gross Motor Total
Calculation
FINE MOTOR
Does your child use a turning motion with her hand while trying to turn doorknobs, wind p toys, twist tops, or screw lids on and off jars?

YesSometimesNot yet
Calculation
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/her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction?

YesSometimesNot yet
Calculation
Can your child string small items such as beads, macaroni, or pasta "wagon wheels" onto a string or shoelace?

YesSometimesNot yet
Calculation
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 line. Does your child copy you by drawing a single line in a horizontal direction?

YesSometimesNot yet
Calculation
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 circle?

YesSometimesNot yet
Calculation
Does your child turn pages in a book, one page at a time?

YesSometimesNot yet
Calculation
Fine Motor Total
Calculation
PROBLEM SOLVING
When looking in the mirror, ask, "Where is ___________________?" (Use your child's name) Does your child point to his/her image in the mirror?

YesSometimesNot yet
Calculation
If your child wants something he cannot reach, does he/she 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)?

YesSometimesNot yet
Calculation
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.)

YesSometimesNot yet
Calculation
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.")
Write your child's response here:
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.

YesSometimesNot yet
Calculation
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.)

YesSometimesNot yet
Calculation
PROBLEM SOLVING TOTAL
Calculation
PERSONAL-SOCIAL
If you do any of the following gestures, does your child copy at least one of them?

Open and close your mouthBlink your eyesPull on your earlobePat your cheek
Check one of the following

YesSometimesNot yet
Calculation
Does your child use a spoon to feed him/herself with little spilling?

YesSometimesNot yet
Calculation
Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she/he cannot turn?

YesSometimesNot yet
Calculation
Does your child put on a coat, jacket, or shirt by him/herself?

YesSometimesNot yet
Calculation
When your child is looking in a mirror and you ask, "Who is in the mirror?" does he/she say either "me" or his/her own name?

YesSometimesNot yet
Calculation
After you put on loose-fitting pants around his/her feet, does your child pull them completely up to his/her waist?

YesSometimesNot yet
Calculation
PERSONAL-SOCIAL TOTAL
Calculation
OVERALL

Parents and providers may use the space below for additional comments.
Do you think your child hears well?

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

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

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

YesNo
Do you think your child walks, runs, and climbs like other toddlers his/her age?

YesNo
If no, explain:
Does either parent have a family history of childhood deafness or hearing impairment?

YesNo
If yes, explain:
Do you have any concerns about your child's vision?

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

YesNo
If yes, explain:
Do you have any concerns about your child's behavior?

YesNo
If yes, please explain:
Does anything about your child worry you?

YesNo
If yes, please explain:
Email
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Ages & Stages Questionnaires®, Third Edition (ASQ-3™),Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved.
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Ages & Stages

Questionnaires

28 months 16 days through 31 months 15 days 30Month Questionnaire

COMMUNICATION

Communication Total

GROSS MOTOR

Gross Motor Total

FINE MOTOR

Fine Motor Total

PROBLEM SOLVING

PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL

PERSONAL-SOCIAL TOTAL

OVERALL