Print Human Touch Wheelchair HT 2580/i Joy 2580 3 Yr ASQ

User Manual: Human Touch Wheelchair HT-2580/iJoy-2580

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Ages & Stages
Questionnaires®

36 Month Questionnaire

34 months 16 days through 38 months 30 days

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

Date ASQ completed:

Child’s information
Middle
initial:

Child’s first name:

Child’s last name:
Child’s gender:
Male

Female

Child’s date of birth:

Person filling out questionnaire
Middle
initial:

First name:

Last name:
Relationship to child:

Street address:

Parent

Guardian

Teacher

Grandparent
or other
relative

Foster
parent

Other:

City:

State/
Province:

ZIP/
Postal code:

Country:

Home
telephone
number:

Other
telephone
number:

E-mail address:

Names of people assisting in questionnaire completion:

Program Information
Child ID #:

Program ID #:

Program name:

P101360100

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

Child care
provider

36 Month Questionnaire

34 months 16 days
through 38 months 30 days

On the following pages are questions about activities children may 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 fill in the circle that indicates
whether your child is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:
✓ Try each activity with your child before marking a response.
❑
✓ Make completing this questionnaire a game that is fun for
❑
you and your child.

Notes:
____________________________________________
____________________________________________

✓ Make sure your child is rested and fed.
❑

____________________________________________

✓ Please return this questionnaire by _______________.
❑

____________________________________________

COMMUNICATION

YES

SOMETIMES

NOT YET

1. When you ask your child to point to her nose, eyes, hair, feet, ears, and
so forth, does she correctly point to at least seven body parts? (She can
point to parts of herself, you, or a doll. Mark “sometimes” if she correctly points to at least three different body parts.)
2. Does your child make sentences that are three or four words long?
Please give an example:

3. 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?
4. 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?”
5. 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”?
6. When you ask, “What is your name?” does your child say both her first
and last names?

COMMUNICATION TOTAL

page 2 of 7

E101360200

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

36 Month Questionnaire
GROSS MOTOR

YES

SOMETIMES

NOT YET

1. Without holding onto anything for support, does your child
kick a ball by swinging his leg forward?

2. Does your child jump with both feet leaving the floor at the
same time?

3. Does your child walk up stairs, using only one foot on
each stair? (The left foot is on one step, and the right foot
is on the next.) She may hold onto the railing or wall. (You
can look for this at a store, on a playground, or at home.)

4. Does your child stand on one foot for about 1 second
without holding onto anything?

5. 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
should be scored as “not yet.”)

6. Does your child jump forward at least 6 inches with both
feet leaving the ground at the same time?

GROSS MOTOR TOTAL

FINE MOTOR

YES
Count as “yes”

1. After your child watches you draw a line from the top of
the paper to the bottom with a pencil, crayon, or pen,
ask her to make a line like yours. Do not let your child
trace your line. Does your child copy you by drawing a
single line in a vertical direction?

E101360300

Count as “not yet”

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

SOMETIMES

NOT YET

page 3 of 7

36 Month Questionnaire
FINE MOTOR

(continued)

YES

SOMETIMES

NOT YET

2. Can your child string small items such as beads,
macaroni, or pasta “wagon wheels” onto a string
or shoelace?

Count as “yes”

3. After your child watches you draw a single circle, ask him
to make a circle like yours. Do not let him trace your
circle. Does your child copy you by drawing a circle?

Count as “not yet”

Count as “yes”

4. After your child watches you draw a line from one
side of the paper to the other side, ask her to make
a line like yours. Do not let your child trace your
line. Does your child copy you by drawing a single
line in a horizontal direction?

Count as “not yet”

5. Does your child try to cut paper with child-safe scissors?
He does not need to cut the paper but must get the
blades to open and close while holding the paper with
the other hand. (You may show your child how to use
scissors. Carefully watch your child’s use of scissors for safety reasons.)
6. When drawing, does your child hold a pencil, crayon, or pen between
her fingers and thumb like an adult does?

FINE MOTOR TOTAL

PROBLEM SOLVING

YES

1. While your child watches, line up four objects like
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.)
2. If your child wants something he cannot reach, does he find a chair or
box to stand on to reach it (for example, to get a toy on a counter or to
“help” you in the kitchen)?

E101360400

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

SOMETIMES

NOT YET

page 4 of 7

36 Month Questionnaire
PROBLEM SOLVING

(continued)

YES

SOMETIMES

NOT YET

3. When you point to the figure and ask your child, “What is
this?” does your child say a word that means a person or
something similar? (Mark “yes” for responses like “snowman,”
“boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”)
Please write your child’s response here:

4. 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 numbers and say, “Say ‘eight two.’” (Your child must
repeat just one series of two numbers for you to answer “yes” to this
question.)
5. 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?
6. 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.)

PERSONAL-SOCIAL

PROBLEM SOLVING TOTAL

YES

SOMETIMES

NOT YET

1. Does your child use a spoon to feed herself with little spilling?
2. Does your child push a little wagon, stroller, or toy on wheels, steering
it around objects and backing out of corners if he cannot turn?
3. 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?
4. Does your child put on a coat, jacket, or shirt by himself?
5. Using these exact words, ask your child, “Are you a girl or a boy?”
Does your child answer correctly?
6. Does your child take turns by waiting while another child or adult takes
a turn?

PERSONAL-SOCIAL TOTAL

E101360500

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

page 5 of 7

36 Month Questionnaire
OVERALL
Parents and providers may use the space below for additional comments.
1.

Do you think your child hears well? If no, explain:

YES

NO

2.

Do you think your child talks like other children her age? If no, explain:

YES

NO

3. Can you understand most of what your child says? If no, explain:

YES

NO

4. Can other people understand most of what your child says? If no, explain:

YES

NO

5. Do you think your child walks, runs, and climbs like other children his age?
If no, explain:

YES

NO

6. Does either parent have a family history of childhood deafness or hearing
impairment? If yes, explain:

YES

NO

E101360600

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

page 6 of 7

36 Month Questionnaire
OVERALL

(continued)

7.

Do you have any concerns about your child’s vision? If yes, explain:

YES

NO

8.

Has your child had any medical problems in the last several months? If yes, explain:

YES

NO

9.

Do you have any concerns about your child’s behavior? If yes, explain:

YES

NO

Does anything about your child worry you? If yes, explain:

YES

NO

10.

E101360700

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

page 7 of 7

36 Month ASQ-3 Information Summary

34 months 16 days through
38 months 30 days

Child’s name: ________________________________________________________ Date ASQ completed: __________________________________________
Child’s ID #: ______________________________________________________ Date of birth: ______________________________________________
Administering program/provider:
1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User’s Guide for details, including how to adjust scores if item
responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.
In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.

2.

3.

Area

Cutoff

Communication

30.99

Gross Motor

36.99

Fine Motor

18.07

Problem Solving

30.29

Personal-Social

35.33

Total
Score

0

5

10

15

20

25

30

35

40

45

50

55

60

TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.
1. Hears well?
Comments:

Yes

NO

6. Family history of hearing impairment?
Comments:

YES

No

2. Talks like other children his age?
Comments:

Yes

NO

7. Concerns about vision?
Comments:

YES

No

3. Understand most of what your child says?
Comments:

Yes

NO

8. Any medical problems?
Comments:

YES

No

4. Others understand most of what your child says? Yes
Comments:

NO

9. Concerns about behavior?
Comments:

YES

No

5. Walks, runs, and climbs like other children?
Comments:

NO

YES

No

Yes

10. Other concerns?
Comments:

ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall
responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
If the child’s total score is in the
If the child’s total score is in the
If the child’s total score is in the

area, it is above the cutoff, and the child’s development appears to be on schedule.
area, it is close to the cutoff. Provide learning activities and monitor.
area, it is below the cutoff. Further assessment with a professional may be needed.

4. FOLLOW-UP ACTION TAKEN: Check all that apply.
______ Provide activities and rescreen in _____ months.

5. OPTIONAL: Transfer item responses
(Y = YES, S = SOMETIMES, N = NOT YET,
X = response missing).

______ Share results with primary health care provider.
______ Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
______ Refer to primary health care provider or other community agency (specify
reason): __________________________________________________________.
______ Refer to early intervention/early childhood special education.
______ No further action taken at this time

1
Communication
Gross Motor
Fine Motor
Problem Solving
Personal-Social

______ Other (specify): ____________________________________________________

P101360800

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.

2

3

4

5

6



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