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

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

Open the PDF directly: View PDF .
Page Count: 8

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

P101360100

Person filling out questionnaire

Child’s information

Date ASQ completed:

Relationship to child:

Parent

Street address:

Names of people assisting in questionnaire completion:

Grandparent

or other

relative

Guardian

Foster

parent

Teacher Child care

provider

Other:

Ages & Stages

Questionnaires®

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.

Child’s first name: Child’s last name:

Child’s date of birth:

First name: Last name:

Middle

initial:

City:

Home

telephone

number:

State/

Province: ZIP/

Postal code:

Other

telephone

number:

E-mail address:

Child’s gender:

Male Female

Middle

initial:

Country:

Program Information

Child ID #:

Program ID #:

Program name:

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

page 2 of 7

E101360200

Month Questionnaire

34 months 16 days

through 38 months 30 days

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.

❑

✓Make sure your child is rested and fed.

❑

✓Please return this questionnaire by _______________.

Notes:

____________________________________________

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.

COMMUNICATION

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 cor-

rectly 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

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 hap-

pening or what action is taking place in the picture (for example, “bark-

ing,” “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?

YES SOMETIMES NOT YET

COMMUNICATION TOTAL

GROSS MOTOR

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

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?

FINE MOTOR

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?

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

36 Month Questionnaire

page 3 of 7

E101360300

YES SOMETIMES NOT YET

GROSS MOTOR TOTAL

YES SOMETIMES NOT YET

Count as “yes”

Count as “not yet”

FINE MOTOR

(continued)

2. Can your child string small items such as beads,

macaroni, or pasta “wagon wheels” onto a string

or shoelace?

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?

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?

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?

PROBLEM SOLVING

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)?

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

36 Month Questionnaire

page 4 of 7

E101360400

YES SOMETIMES NOT YET

FINE MOTOR TOTAL

YES SOMETIMES NOT YET

Count as “not yet”

Count as “yes”

Count as “not yet”

PROBLEM SOLVING

(continued)

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 neces-

sary, 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

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 mir-

ror?” 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?

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

36 Month Questionnaire

page 5 of 7

E101360500

YES SOMETIMES NOT YET

PROBLEM SOLVING TOTAL

YES SOMETIMES NOT YET

PERSONAL-SOCIAL TOTAL

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

36 Month Questionnaire

page 6 of 7

E101360600

OVERALL

Parents and providers may use the space below for additional comments.

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

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

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

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

5. Do you think your child walks, runs, and climbs like other children his age?

If no, explain:

6. Does either parent have a family history of childhood deafness or hearing

impairment? If yes, explain:

YES NO

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

36 Month Questionnaire

page 7 of 7

E101360700

OVERALL

(continued)

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

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

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

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

YES NO

Ages & Stages Questionnaires®, Third Edition (ASQ-3

™

Squires & Bricker

P101360800

3. 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 area, it is above the cutoff, and the child’s development appears to be on schedule.

If the child’s total score is in the area, it is close to the cutoff. Provide learning activities and monitor.

If the child’s total score is in the area, it is below the cutoff. Further assessment with a professional may be needed.

Child’s name: ________________________________________________________

Child’s ID #: ______________________________________________________

Administering program/provider:

Month ASQ-3 Information Summary

34 months 16 days through

38 months 30 days

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

123456

2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See

ASQ-3 User’s Guide,

Chapter 6.

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.

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

0 5 10 15 20 25 30 35 40 45 50 55 60

Total

Area Cutoff Score

30.99

36.99

18.07

30.29

35.33

4.FOLLOW-UP ACTION TAKEN: Check all that apply.

______ Provide activities and rescreen in _____ months.

______ 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

______ Other (specify): ____________________________________________________

5. OPTIONAL: Transfer item responses

(Y = YES, S = SOMETIMES, N = NOT YET,

X = response missing).

1. Hears well? Yes NO

Comments:

2. Talks like other children his age? Yes NO

Comments:

3. Understand most of what your child says? Yes NO

Comments:

4. Others understand most of what your child says? Yes NO

Comments:

5. Walks, runs, and climbs like other children? Yes NO

Comments:

6. Family history of hearing impairment? YES No

Comments:

7. Concerns about vision? YES No

Comments:

8. Any medical problems? YES No

Comments:

9. Concerns about behavior? YES No

Comments:

10. Other concerns? YES No

Comments:

Date ASQ completed: __________________________________________

Date of birth: ______________________________________________

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

Navigation menu

Versions of this User Manual:

Views

Navigation