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Ages & Stages Questionnaires® 10 Month Questionnaire 9 months 0 days through 10 months 30 days Please provide the following information. Use black or blue ink only and print legibly when completing this form. Date ASQ completed: Baby’s information Middle initial: Baby’s first name: Baby’s last name: If baby was born 3 or more weeks prematurely, # of weeks premature: Baby’s date of birth: Baby’s gender: Male Female Person filling out questionnaire Middle initial: First name: Last name: Relationship to baby: 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 Baby ID #: Age at administration in months and days: Program ID #: If premature, adjusted age in months and days: Program name: P101100100 Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved. Child care provider 10 Month Questionnaire 9 months 0 days through 10 months 30 days On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet. Important Points to Remember: ✓ Try each activity with your baby before marking a response. ❑ ✓ Make completing this questionnaire a game that is fun for ❑ you and your baby. Notes: ____________________________________________ ____________________________________________ ✓ Make sure your baby is rested and fed. ❑ ____________________________________________ ✓ Please return this questionnaire by _______________. ❑ ____________________________________________ COMMUNICATION YES SOMETIMES NOT YET 1. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”? 2. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you? 3. Does your baby make two similar sounds like “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.) 4. If you ask your baby to, does he play at least one nursery game even if you don’t show him the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)? 5. Does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back,” without your using gestures? 6. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.) COMMUNICATION TOTAL GROSS MOTOR YES SOMETIMES NOT YET 1. If you hold both hands just to balance your baby, does she support her own weight while standing? 2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support? page 2 of 6 E101100200 Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved. 10 Month Questionnaire GROSS MOTOR (continued) YES SOMETIMES page 3 of 6 NOT YET 3. When you stand your baby next to furniture or the crib rail, does she hold on without leaning her chest against the furniture for support? 4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position? 5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)? 6. Does your baby walk beside furniture while holding on with only one hand? GROSS MOTOR TOTAL FINE MOTOR YES SOMETIMES NOT YET 1. Does your baby pick up a small toy with only one hand? 2. Does your baby successfully pick up a crumb or Cheerio by using her thumb and all of her fingers in a raking motion? (If she already picks up a crumb or Cheerio, mark “yes” for this item.) 3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.) 4. After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (The string may be attached to a toy.) * 5. Does your baby pick up a crumb or Cheerio with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it. 6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy? FINE MOTOR TOTAL *If Fine Motor Item 5 is marked “yes” or “sometimes,” mark Fine Motor Item 2 “yes.” E101100300 Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved. 10 Month Questionnaire PROBLEM SOLVING YES SOMETIMES NOT YET 1. Does your baby pass a toy back and forth from one hand to the other? 2. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute? 3. When holding a toy in his hand, does your baby bang it against another toy on the table? 4. While holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)? 5. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)? 6. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.) PROBLEM SOLVING TOTAL PERSONAL-SOCIAL YES SOMETIMES NOT YET 1. While your baby is on her back, does she put her foot in her mouth? 2. Does your baby drink water, juice, or formula from a cup while you hold it? 3. Does your baby feed himself a cracker or a cookie? 4. When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn’t let go of it? (If she already lets go of the toy into your hand, mark “yes” for this item.) 5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve? 6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand? PERSONAL-SOCIAL TOTAL E101100400 Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved. page 4 of 6 10 Month Questionnaire OVERALL Parents and providers may use the space below for additional comments. 1. Does your baby use both hands and both legs equally well? If no, explain: YES NO 2. When you help your baby stand, are his feet flat on the surface most of the time? If no, explain: YES NO 3. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain: YES NO 4. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain: YES NO 5. Do you have concerns about your baby’s vision? If yes, explain: YES NO 6. Has your baby had any medical problems in the last several months? If yes, explain: YES NO E101100500 Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved. page 5 of 6 10 Month Questionnaire OVERALL (continued) 7. Do you have any concerns about your baby’s behavior? If yes, explain: YES NO 8. Does anything about your baby worry you? If yes, explain: YES NO E101100600 Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved. page 6 of 6 10 Month ASQ-3 Information Summary 9 months 0 days through 10 months 30 days Baby’s name: ______________________________________________________ Date ASQ completed: __________________________________________ Baby’s ID #: ______________________________________________________ Date of birth: ______________________________________________ Was age adjusted for prematurity when selecting questionnaire? Administering program/provider: Yes No 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 22.87 Gross Motor 30.07 Fine Motor 37.97 Problem Solving 32.51 Personal-Social 27.25 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. Uses both hands and both legs equally well? Comments: Yes NO 5. Concerns about vision? Comments: YES No 2. Yes NO 6. Any medical problems? Comments: YES No 3. Concerns about not making sounds? Comments: YES No 7. Concerns about behavior? Comments: YES No 4. Family history of hearing impairment? Comments: YES No 8. Other concerns? Comments: YES No Feet are flat on the surface most of the time? 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 baby’s total score is in the If the baby’s total score is in the If the baby’s total score is in the area, it is above the cutoff, and the baby’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): ____________________________________________________ P101100700 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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