9 months 0 days through 9 months 30 days 9Month Questionnaire

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

Date ASQ completed:

Date

Baby's Full Name:

Baby's Date of Birth

Date

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 box that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

1. Try each activity with your baby before marking a response.

2. Make completing this questionaire a game that is fun for you and your baby.

3. Make sure your baby is rested and fed.

Does your baby make sounds like "da," "ga," and "ba"?

YesSometimesNot yet

Calculation

If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?

YesSometimesNot yet

Calculation

Does your baby make two similar sounds like "ba-ba", "da-da," or "ga-ga"? (The sounds do not need to mean anything.)

YesSometimesNot yet

Calculation

If you ask your baby to, does he/she play at least one nursery game even if you don't show him/her the activity yourself such as "bye-bye," "Peekaboo," "clap your hands," "So Big")?

YesSometimesNot yet

Calculation

Does your baby follow one simple command, such as "Come here," "Give it to me," or "Put it back," without your using gestures?

YesSometimesNot yet

Calculation

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.)

YesSometimesNot yet

Calculation

COMMUNICATION TOTAL

If you hold both hands just to balance your baby, does he/she support his/her own weight while standing?

YesSometimesNot yet

Calculation

When sitting on the floor, does your baby sit up straight for several minutes without using his/her hands for support?

YesSometimesNot yet

Calculation

When you stand your baby next to furniture or the crib rail, does he/she hold on without leaning his/her chest against the furniture for support?

YesSometimesNot yet

Calculation

When holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?

YesSometimesNot yet

Calculation

Does your baby walk beside furniture while holding on with only one hand?

YesSometimesNot yet

Calculation

GROSS MOTOR TOTAL

Does your baby pick up a small toy with only one hand?

YesSometimesNot yet

Calculation

Does your baby successfully pick up a crumb or Cheerio by using his/her thumb and all of her fingers in a raking motion? (If she already picks up a crumb or Cheerio, mark "yes" for this item.)

YesSometimesNot yet

Calculation

Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)

YesSometimesNot yet

Calculation

After one or two tries, does your baby pick up a piece of string with his/her first finger and thumb? (The string may be attached to a toy.)

YesSometimesNot yet

Calculation

Does your baby pick up a crumb or Cheerio with the tips of his/her thumb and a finger? He/she may rest his/her arm or hand on the table while doing it.

YesSometimesNot yet

Calculation

Does your baby put a small toy down, without dropping it, and then take her hand off the toy

YesSometimesNot yet

Calculation

FINE MOTOR TOTAL

Does your baby pass a toy back and forth from one hand to the other?

YesSometimesNot yet

Calculation

Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?

YesSometimesNot yet

Calculation

When holding a toy in his/her hand, does your baby bang it against another toy on the table?

YesSometimesNot yet

Calculation

While holding a small toy in each hand, does your baby clap the toys together (like "Pat-a-cake")?

YesSometimesNot yet

Calculation

Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?

YesSometimesNot yet

Calculation

After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (be sure the toy is completely hidden.)

YesSometimesNot yet

Calculation

PROBLEM SOLVING TOTAL

While your baby is on his/her back, does he/she put his/her foot in his/her mouth?

YesSometimesNot yet

Calculation

Does your baby drink water, juice, or formula from a cup while you hold it?

YesSometimesNot yet

Calculation

Does your baby feed him/herself a cracker or a cookie?

YesSometimesNot yet

Calculation

When you hold out your hand and ask for his/her toy, does your baby offer it to you even if he/she doesn't let go of it? (If he/she already lets go of the toy into your hand, mark "yes" for this item.)

YesSometimesNot yet

Calculation

When you dress your baby, does he/she push his/her arm through a sleeve once his/her arm is started in the hole of a sleeve?

YesSometimesNot yet

Calculation

When you hold out your hand and ask for his/her toy, does your baby let go of it into your hand?

YesSometimesNot yet

Calculation

PERSONAL SOCIAL TOTAL

Does your baby use both hands and both legs equally well?

YesNo

If no, explain:

When you help your baby stand, are his/her feet flat on the surface most of the time?

YesNo

If no, explain:

Do you have concerns that your baby is too quiet or does not make sounds like other babies?

YesNo

If yes, explain:

Does either parent have a family history of childhood deafness or hearing impairment?

YesNo

If yes, explain:

Do you have concerns about your baby's vision?

YesNo

If yes, explain:

Has your baby had any medical problems in the last several months?

YesNo

If yes, explain:

Do you have any concerns about your baby's behavior?

YesNo

If yes, explain:

Does anything about your baby worry you?

YesNo

If yes, explain:

Ages & Stages

Questionnaires

9 months 0 days through 9 months 30 days 9Month Questionnaire

COMMUNICATION

GROSS MOTOR

FINE MOTOR

PROBLEM SOLVING

PERSONAL-SOCIAL

OVERALL