Ages & Stages Questionnaires’: A rarent-Completed, Child-Monitoring System Second Edition By Diane Bricker and Jane Squires with assistance from Linda Mounts, LaWanda Potter, Robert Nickel, Elizabeth Twombly, and Jane Farrell Copyright © 1999 by Paul H. Brookes Publishing Co. 33 Month Questionnaire On the following pages are questions about activities children do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please check the box that tells whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: B&B BEB&SB GAB Be sure to try each activity with your child before checking a box. Try to make comploting this questionnaire a game that is fun for you and your child Make sure your child is rested, fed, and ready to play. Please returm this questionnaire by If you have any questions or concerns about your child or about this questionnaire, please call; — Look forward to filling out another questionnaire in _____. months,Ages & Stages Questionnaires’: A Parent Completed, Child-Monitoring System Second Edition By Diane Bricker and Jane Squires vith assistance from Linda Mounts, LaWanda Potter, Robert Nickel, Elizabeth Twombly, and Jane Farrell Copyright © 1999 by Paul H. Brookes Pubishing Co, 33 Month Questionnaire Please provide the following information. Cauepecpe eee eee Child's date of birth: Today's date; — Parson filing out this questionnaire: What is your relationship to the chia? Your telephone: — Your mailing address Clty: — eee State; tr code» List people assisting in questionnaire completion: ‘Administering program or provider; <<<Yes COMMUNICATION 60 sure fo try each activity mith your child. 4. When you ask her to paint fo her nose, eyes, hair, feet, ears, and 60 forth, does you child correctly point ta atleast sevan body parts? (She ccah point 0 paris of herself, you, ora dol) 2. Does your child make sentences that are three or four words long? Please give an example: 3. Without giving him help by pointng or using gestures, ask your child to “Put the shoe onthe tabe” and “Pl the book undor the chai Does your child cary out both ofthese directions conecy? a 4. When fooking at a picture book, does your child tell you what is hap. pening or what action is taking place in the picture? (For exarmple, “Barking? “Running; “Eating” and “Crying”) You may ask, “What is the dog {or boy) doing?” '5, Shoe your child how a zipper on a coat moves up and down, and sey, "See, this goes up and down. Put the zigper to the middle, and ask your child fo mave the zippor down. Return the zigper 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 chi to move it up oF down, Does your child consistently move the zipper up when you say "up" and dawn when you say “down”? a 6 When you ask, "What is your name’ ‘and last names? does your chiki say both ner fist GROSS MOTOR —2e sure to try each activity with your child 1. Does your child run faily well, stopping hersetf without o taming int things or aling? AS « wmmimagcmintrgt onset fh cil kick a ball by swinging his 'eg forward? ge a 3. Does your child jump with both feet leaving the flr at the seme time? a oss 8 Sanes Queosonnave’ Seca Eon, Bier et ° a Pau H Brookes PUG GO. > SOMETIMES NOT YET oO a a COMMUNICATION TOTAL Oo a a 53 monthsYES SOMETIMES NOT YET GROSS MOTOR — (continuod) 4. Does your cild walk up stairs, using only one foot ‘on each star? (The left foot is on one step, and the right foot ison the next) She may hold onto the railing or wall, (You can look for this at a store, on @ playground, or at home.) Qa a a ~ 5. Does your child stand on one foot for about 1 second » «without holding onto anything? a Qa Q —_ 6, While standing, does your child throw a ball overhand by raising his arm to shoulder height and throwing the ball ‘forward? (Dropping the ball or throwing the ball underhand >> ‘does not count) a a a pis GROSS MOTOR TOTAL __ FINEMOTOR Be sure to iy each activity with your chi. ‘Count ass" 4. After he watches you draw a line from the top ‘of the paper fo the bottom with a pencil, crayon, { fr pen, ask your child to make a line like yours. Do nat let your child trace your ine. Does your child copy you by drawing a single fine in a vertical direction” iy ; 5 a a a aa 2. Does your child thread a shoelace through either a bead or an eyelet af a shoo? Zz Se a a a a 4. Afarshe watches you awa Comes Tne tom ono side 0 he paper — EN maa che ckyeorenkd TT torah ane Me your. Do fotletyour id iaoe your SATE norman byaroningacioge ine na > a a a horizontal direction? aes 8 Sages Questonnaiee, Sacond Ester, Breer sa (2158 Pau H Brookes Pabising Oo 4 33 monthsYES SOMETIMES NOT YET INEMOTOR (continued) 4. After he watches you draw a single circle, enn ask your chido make a circle ike yours. oO oO Do not lt him trace your eel. Does Your chid copy youby crowing ace? co 5. Does your child turn pages in a book, one page at a time? Qa a Q Does your child try to cut paper with child-safe scissors? She does not need to cut the paper but must {got the blades to open and close while holding the ~~ ppapor with the other hand, (You may show your child EC hhow to uso scissors. Carefully watch your childs use —*~ of scissors for safely reasons.) a Q a — FINE MOTOR TOTAL —— PROBLEM SOLVING Be sure fo try each activity with your child. 1. When looking in the mitror, as, “Where is__?" (Use your child's name.) Does your child point to hhor image in the minror? 2. While your ehiid watches, line up four ‘objects Ike 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.) Qa Qa a _ 2, IHyour ehild wants something he cannot reach, does he find a chair ‘of box to stand on to reach it? Qa Qa Q paieisy 4, When you point tothe figure and ask your child, “Wat is this?" does your child say a word that means a person?” Responses ko “snowman” “boy? "man? “gis and “Daddy” are correct a a a a Please write your chil’s response here 5, When you say, "Say seven three” dos your child repeat just the two numbers in the correct order? Do not repeat the numbers, I necessary, try another pait of numbers and say, “Say eight wo” ‘Your child must repeat just one series of two numbers for you to answer "yes" to this question. Q Q Q — 6, Alter she draws a picture,” even a simple scribble, docs your child toll you what she drow? You may say "Tel! me about your picture.” or ask, “What is this?" to prompt her. a Qa a a PROBLEM SOLVING TOTAL ‘hoes 8 Stagns Quesinnsiee. Second Eon, Beko et ("is Paul Brookes Pubihing Co 5 33 monthsYES PERSONAL-SOCIAL — Be sure to try each activity with your chi 4. Does your child use a spoon to toad herself with litle sping? 2. Does your child push a litle shopping cart, stroller, or wagon, steering it araund objects and backing out of corners if he cannot turn? 3, Does your child put an a coal, jacket, or shirt by herself? 4. After you put on loose-fiting pants around his feet, coes your child pull them completely up 10 his waist? 5. When she is looking in a mitor and you ask, ‘Whe is in the mirror?" ‘does your child say either "Me" or her own name? po oe ef 6. _Ushng these exact words, ask your child, "Are you a gi or & boy?” ‘Boas your child answer correctly? o OVERALL Parents and providers may use the space below or the back of this shest for adaitional comments. 1, De you think your ehild hears well? no, explain 2. Do you think your child talks lke other toddlers her age? Wo, explain: 3. Can you understand most of what your child says? A es cece seca eeeceececee eee eee eee 4, Bo you think your child waiks, runs, and climbs hike other toddlers his ago? no, explain oo oc oO a 5. Does either parent have a family history of childhood deafness or hearing impairment? yee epi eee eee 6. Do you have concerns about your childs vision? gam expt: 7. Has your child had any medical problems inthe last several months? fipeatee ans Secure eee 8 Does anything about your child worry you? Byssjenpldins Ages & Stages Qutstovrie’ Second Esti, Bice a B70 owl SroceesPustoning Oo 6 SOMETIMES NOT YET ooocac oa a PERSONAL-SOCIAL TOTAL yes yes) ves) ves ves ves yes) yes) no Noa nod Koa noQ no nou noQ 33 months33 Month ASQ Information Summary Date of birth Child's namo: Person filing out the ASO: Relationship to cil Mailing address: cy State: ap Assisting In ASO completion: “Tolophone: Today's date: OVERALL: Please transfer the answers in the Overall section of the questionnaire by crcing "yes" or no” and reporting any comments 1. Hears wel? Yes NO 5, Family history of heaving impairment?” Yes NO. Comments: Comments: 2. Talks like otter children? ves NO 6. Vision concems? YES NO Comments: Comments 3. Understand child? YES NO 7. Recent medical problems? Yes NO. (Comments: ‘Comments: 4, Walks, runs, and climbs like others? YES NO 8 Other concerns? YES NO Comments: Comments: SCORING THE QUESTIONNAIRE 4. Be sure each item has been answered. ifan item cannet be answered, reer tothe ratio scoring procedure in The ASQ User's Guide. 2. Score each item on the questionnaire by wating the appropriate number on the line by each item answr, YES=10 SOMETIMES =5 NOT YET 3. Add up the tem scores for each area, and record these totals inthe space provided for area totals ‘A. Indicate the child's total score for each area by filing in the appropriate circle on the chart below. For example, ifthe total score for the Communication area was 60, fil in the circle below 50 in the first row. be 0 5 a ee ‘Communication Oo oo 0 90 Gross motor S O10 Oo oO. Fine motor Qurginmue. Problem solving Chiou Persons oi O_O 0 oO rr rr ee ee) 6 885 amin tho backend cites for each rein he chart above, fhe cid tol coe fats wih tho are, to child appenrsobe cong wal ni area a is era § URS CdS te ooo lis wah a areata wv artestonal Th child may ncedfarhrevaluaon, OPTIONAL: The spectcanswer to cach em on he qusstonnaive can be recorded below on tho summary cart x ce Ean Carmi Repo ARs Paar cmmuan Pete) "OOD! 99] +0! +'O}O) :/O10|9 L482 2660) O00 O10) 7QO0 +000 goer [8 000! OI09} 2019 sIQiD{9) »'QI010 Fine maior pes! «OOO sO! «OOO, «OO'O «O0'O| F pienso 1368] SOOO] sOO|IO sO]OlO] -|OO'O +|OO|O: poate sO] OOO OOO) OOO) *[OlOjO) Cee ee eee een oon ‘Administering program or provider: ‘Ages & Stages Ouestonnanes®, Second Eon Bicker (SFiaee Paul, Groates Pushing Co 7 33 months