R: ASQ-3 42 Month

Ages and Stages 42 Month Form Create a HIPAA Compliant R: ASQ-3 42 Month today.

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Please provide the following information:
Date ASQ completed (MM/DD/YYYY):
Child's Information
Child's Name

First Name Last Name
Child's Date of Birth

- Month - Day Year
If child was born 3 or more weeks prematurely, # of weeks premature:
Child's Gender

Male Female
Person filling out Questionnaire
Full Name

First Name Last Name
Street Address:
Relationship to child:

Parent Guardian Teacher Child Care Provider Grandparent or other relative Foster Parent Other option
City
State/Province
Zip/Postal Code
Country
Home Telephone Number
Other Telephone Number
Email Address
Names of People Assisting in Questionnaire Completion
Program Information
Child ID #:
Age at administration, in months and days:

- Month - Day Year
Program ID #:
If premature, adjusted age, in months and days:

- Month - Day Year
Program Name:

	Yes	Sometimes	Not Yet
1. 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?
2. 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?"
3. Show your child how a zipper on a coat moves up and down, and say, "See, this goes up and down." Put the zipper to the middle, and ask your child to move the zipper down. Return the zipper to the middle, and ask your child to move the zipper up. Do this several times, placing the zipper in the middle before asking your child to move it up or down. Does your child consistently move the zipper up when you say "up" and down when you say "down"?
4. When you ask, "What is your name?" does your child say both her first name and last name?
5. Without your giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down," or "Give me the pen, open the book, and stand up."
6. Does your child use all of the words in a sentence (for example, "a," "the," "am," "is," and "are") to make complete sentences, such as "I am going to the park," or "Is there a toy to play with?" or "Are you coming, too?"

	Yes	Sometimes	Not Yet
5. Does your child put together a five-to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)
6. Using the shape at right to look at, does your child copy it onto a large piece of paper using a pencil, crayon, or pen, without tracing? (Your child's drawing should look like the design of the shape, except it may be different in size.)

	Yes	Sometimes	Not Yet
2. 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 number and say, "Say 'eight two.'" Your child must repeat just one series of two numbers for you to answer "yes" to this question.
3. Show your child how to make a bridge with blocks, boxes, or cans, like the example. Does your child copy you by making one like it?

	Yes	Sometimes	Not Yet
4. When you say, "Say 'five eight three,'" does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, "Say 'six nine two'" (Your child must repeat just one series of three numbers for you to answer "yes" to this question.)
5. When asked, "Which circle is the smallest?" does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)

	Yes	Sometimes	Not Yet
1. When your child is looking in a mirror and you ask, "Who is in the mirror?" does she say either "me" or her own name?
2. Does your child put on a coat, jacket, or shirt by himself?
3. Using these exact words, ask your child, "Are you a girl or a boy?" Does your child answer correctly?
4. Does your child take turns by waiting while another child or adult takes a turn?
5. Does your child serve himself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?
6. Does your child wash his hands using soap and water and dry off with a towel without help?

R: ASQ-3 42 Month

Child's Information

Person filling out Questionnaire

Program Information

Overall