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ASQ-3: 20 Month Questionnaire & ASQ:SE-2

Please complete this questionnaire about your child’s development and social-emotional skills. Answer based on what your child does most of the time.

Child Information

Child's gender *

Person Filling Out Questionnaire

Your relationship to the child *

Program Information

Communication

Does your child put two or more words together to make short phrases (for example, “more milk,” “go out”)? *
Does your child say at least ten different words on their own (not just repeating you)? *
When you ask your child to point to common objects (like “ball,” “cup,” “shoe”), does your child point to the correct item? *
Does your child follow simple directions without gestures (for example, “Put the toy on the table,” “Come here”)? *
Does your child name familiar pictures in a book when you ask (for example, “Where is the dog?”)? *
Does your child use words to ask for help or to ask for things (for example, “help,” “up,” “water”)? *

Gross Motor

Does your child walk up stairs with your hand or a rail, putting one foot on each step or the same foot on each step? *
Can your child run without falling frequently or bumping into things? *
Does your child kick a ball forward without holding onto anything for support? *
Does your child climb onto a low chair, couch, or bed and get down again without help? *
While standing, can your child squat down to pick up a toy and stand back up without holding onto anything? *
Can your child throw a small ball overhand (not just drop it) toward you or another person? *

Fine Motor

Does your child stack small blocks or similar objects, building a tower of four or more blocks by themself? *
Does your child turn the pages of a book on their own (several pages at a time is okay)? *
When given a crayon or pencil, does your child make marks or scribbles on paper without help? *
Can your child place small objects (like blocks or pegs) into a container such as a box, cup, or bowl? *
Does your child use one hand more than the other for eating or playing (showing a preferred hand)? *
Can your child turn knobs, twist jar lids, or try to turn door handles using one hand? *

Problem Solving

Without showing your child how, do they scribble back and forth if you hand them a crayon and paper? *
Does your child try to copy simple lines or marks you draw, such as a vertical line or a circle (even if not perfect)? *
Can your child match simple shapes or pieces into a matching hole or puzzle board (for example, circle piece into circle hole)? *
If you hide a small toy under a cloth or behind an object while your child watches, do they look for it and find it? *
Does your child use everyday objects in pretend play (for example, holding a phone to ear, feeding a doll, pretending to drink from an empty cup)? *
When you show your child how to do a simple task (like stacking rings or pushing buttons on a toy), do they try to copy what you did? *

Personal–Social

Does your child feed themself with a spoon, even if they spill a little? *
Does your child help with dressing by pushing arms through sleeves or lifting feet for pants or socks? *
Does your child copy actions like brushing hair, washing hands, or wiping the table? *
Does your child show affection to familiar people (for example, hugs, kisses, or cuddling)? *
Does your child play simple pretend games, such as feeding a doll or stuffed animal, or pretending to talk on the phone? *
When playing near other children, does your child watch them and sometimes try to join in the play? *

ASQ:SE-2 – Social-Emotional

Response options: Z = rarely or never,  V = sometimes,  X = often,  V (concern) = sometimes, and this is a concern for you.

Does your child look at you when you talk to him? *
When you leave, does your child stay upset and cry for more than an hour? *
Does your child laugh or smile when you play with her? *
Does your child look for you when a stranger comes near? *
Is your child's body relaxed? *
Does your child like to be hugged or cuddled? *
When upset, can your child calm down within 15 minutes? *
Does your child stiffen and arch his back when picked up? *
Does your child cry, scream, or have tantrums for long periods of time? *
Is your child interested in things around her, such as people, toys, and foods? *
Does your child do things over and over and get upset when you try to stop him? (e.g., rocking, flapping hands, spinning, etc.) *
Does your child have eating problems? (e.g., stuffing food, vomiting, eating non-food items) *
Does your child have trouble falling asleep at naptime or at night? *
Do you and your child enjoy mealtimes together? *
Does your child sleep at least 10 hours in a 24-hour period? *
When you point at something, does your child look in the direction you are pointing? *
Does your child get constipated or have diarrhea? *
Does your child let you know how he is feeling with gestures or words? (e.g., hunger, pain, tiredness) *
Does your child follow simple directions? (e.g., sitting down when asked) *
Does your child like to play near or be with family and friends? *
Does your child check to make sure you are near when exploring new places? *
Does your child like to hear stories or sing songs? *
Does your child hurt himself on purpose? *
Does your child like to be around other children? (e.g., moving close to or looking at other children) *
Does your child try to hurt other children, adults, or animals? (e.g., kicking or biting) *
Does your child try to show you things by pointing at them and looking back at you? *
Does your child make sounds or use words or gestures to let you know he wants something? (e.g., reaching) *
Does your child play with objects by pretending? (e.g., pretending to talk on the phone, feed a doll) *
Does your child wake three or more times during the night? *
Does your child respond to her name when you call her? (e.g., turning head and looking) *
Has anyone shared concerns about your child's behaviors? If sometimes or often, please explain. *
Do you have concerns about your child's eating or sleeping behaviors? If yes, please explain. *
Does anything about your child worry you? If yes, please explain. *

ASQ-3 – Overall

Do you think your child hears well? *
Do you think your child talks like other children their age? *
Can you understand most of what your child says? *
Do you have concerns about how your child walks, runs, or climbs? *
Do you have concerns about your child's vision? *
Has your child had any medical problems recently? *
Do you have concerns about your child's behavior? *
Is there anything else about your child that worries you? *
Are daily routines (sleep, feeding, play) generally going smoothly? *

Your responses are stored securely and shared only with your care team for developmental review.