17 months 0 days through 18 months 30 days 18Month Questionnaire

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

Date ASQ completed:

Date

Child's full name:

Child's Date of Birth

Date

17 months 0 days 18Month Questionnaire 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.

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.

When your child wants something, does he/she tell you by pointing to it?

YesSometimesNot yet

Calculation

When you ask your child to, does he/she go into another room to find a familiar toy or object? (You might ask, "Where is your ball?" or say, "Bring me your coat," or "Go get your blanket.")

YesSometimesNot yet

Calculation

Does your child say eight or more words in addition to "Mama" and "Dada"?

YesSometimesNot yet

Calculation

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 his/her words are difficult to understand.)

YesSometimesNot yet

Calculation

Without your showing him/her, 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.)

YesSometimesNot yet

Calculation

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?")

YesSometimesNot yet

Calculation

Please give an example of your child's word combinations:

COMMUNICATION TOTAL SCORE

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

YesSometimesNot yet

Calculation

Does your child move around by walking, rather than by crawling on her hands and knees?

YesSometimesNot yet

Calculation

Does your child walk well and seldom fall?

YesSometimesNot yet

Calculation

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)?

YesSometimesNot yet

Calculation

Does your child walk down stairs if you hold onto one of his/her hands? He/she may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)

YesSometimesNot yet

Calculation

When you show your child how to kick a large ball, does he/she try to kick the ball by moving his/her leg forward or by walking into it? (If your child already kicks a ball, mark "yes" for this item.)

YesSometimesNot yet

Calculation

GROSS MOTOR TOTAL

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

YesSometimesNot yet

Calculation

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.)

YesSometimesNot yet

Calculation

Does your child make a mark on the paper with the tip of a crayon (or pencil or pen) when trying to draw?

YesSometimesNot yet

Calculation

Does your child stack three small blocks or toys on top of each other by his/herself?

YesSometimesNot yet

Calculation

Does your child turn the pages of a book by his/herself? (He/she may turn more than one page at a time.)

YesSometimesNot yet

Calculation

Does your child get a spoon into his/her mouth right side up so that the food usually doesn't spill?

YesSometimesNot yet

Calculation

FINE MOTOR TOTAL

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

YesSometimesNot yet

Calculation

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

YesSometimesNot yet

Calculation

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/her how.) (You can use a soda bottle or a baby bottle.)

YesSometimesNot yet

Calculation

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

YesSometimesNot yet

Calculation

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 child scribbles back and forth.)

YesSometimesNot yet

Calculation

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/her how.)

YesSometimesNot yet

Calculation

PROBLEM SOLVING TOTAL

While looking at him/herself in the mirror, does your child offer a toy to his/her own image?

YesSometimesNot yet

Calculation

Does your child play with a doll or stuffed animal by hugging it?

YesSometimesNot yet

Calculation

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

YesSometimesNot yet

Calculation

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

YesSometimesNot yet

Calculation

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

YesSometimesNot yet

Calculation

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

YesSometimesNot yet

Calculation

PERSONAL SOCIAL TOTAL

Do you think your child hears well?

YesNo

If no, explain:

Do you think your child talks like other toddlers his/her age?

YesNo

If no, explain:

Can you understand most of what your child says?

YesNo

If no, explain:

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 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, explain:

Does anything about your child worry you?

YesNo

If yes, explain:

Date ASQ completed:

Date

Ages & Stages

Questionnaires

17 months 0 days through 18 months 30 days 18Month Questionnaire

COMMUNICATION

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL