Print ASQ10AL Ages And Stages Questionnaire 10 Mos
User Manual: ASQ10AL
Open the PDF directly: View PDF 
.
Page Count: 7
Ages & Stages Questionnaires®, Third Edition (ASQ-3
™
),
Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
P101100100
Person filling out questionnaire
Baby’s information
Date ASQ completed:
Relationship to baby:
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
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.
10
Baby’s first name: Baby’s last name:
Baby’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:
If baby was born 3
or more weeks
prematurely, # of
weeks premature:
Baby’s gender:
Male Female
Middle
initial:
Country:
Program Information
Age at administration in months and days:
Baby ID #:
Program ID #:
Program name:
If premature, adjusted age in months and days:
Ages & Stages Questionnaires®, Third Edition (ASQ-3
™
),
Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
page 2 of 6
E101100200
Month Questionnaire
10
9 months 0 days
through 10 months 30 days
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.
❑
✓Make sure your baby is rested and fed.
❑
✓Please return this questionnaire by _______________.
Notes:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
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 indi-
cates whether your baby is doing the activity regularly, sometimes, or not yet.
COMMUNICATION
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,” “Peeka-
boo,” “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.)
GROSS MOTOR
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?
YES SOMETIMES NOT YET
COMMUNICATION TOTAL
YES SOMETIMES NOT YET
GROSS MOTOR
(continued)
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?
FINE MOTOR
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?
Ages & Stages Questionnaires®, Third Edition (ASQ-3
™
),
Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
10 Month Questionnaire
page 3 of 6
E101100300
YES SOMETIMES NOT YET
GROSS MOTOR TOTAL
YES SOMETIMES NOT YET
FINE MOTOR TOTAL
*If Fine Motor Item 5 is
marked “yes” or “sometimes,”
mark Fine Motor Item 2 “yes.”
*
PROBLEM SOLVING
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.)
PERSONAL-SOCIAL
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?
Ages & Stages Questionnaires®, Third Edition (ASQ-3
™
),
Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
10 Month Questionnaire
page 4 of 6
E101100400
YES SOMETIMES NOT YET
PROBLEM SOLVING TOTAL
YES SOMETIMES NOT YET
PERSONAL-SOCIAL TOTAL
Ages & Stages Questionnaires®, Third Edition (ASQ-3
™
),
Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
10 Month Questionnaire
page 5 of 6
E101100500
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
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:
2. When you help your baby stand, are his feet flat on the surface most of the time?
If no, explain:
3. Do you have concerns that your baby is too quiet or does not make sounds like
other babies? If yes, explain:
4. Does either parent have a family history of childhood deafness or hearing
impairment? If yes, explain:
5. Do you have concerns about your baby’s vision? If yes, explain:
6. Has your baby had any medical problems in the last several months? If yes, explain:
Ages & Stages Questionnaires®, Third Edition (ASQ-3
™
),
Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
10 Month Questionnaire
page 6 of 6
E101100600
OVERALL
(continued)
7. Do you have any concerns about your baby’s behavior? If yes, explain:
8. Does anything about your baby worry you? If yes, explain:
YES NO
YES NO
Ages & Stages Questionnaires®, Third Edition (ASQ-3
™
),
Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
P101100700
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 baby’s total score is in the area, it is above the cutoff, and the baby’s development appears to be on schedule.
If the baby’s total score is in the area, it is close to the cutoff. Provide learning activities and monitor.
If the baby’s total score is in the area, it is below the cutoff. Further assessment with a professional may be needed.
Baby’s name: ______________________________________________________
Baby’s ID #: ______________________________________________________
Administering program/provider:
Date ASQ completed: __________________________________________
Date of birth: ______________________________________________
Was age adjusted for prematurity
when selecting questionnaire? Yes No
Month ASQ-3 Information Summary
10
9 months 0 days through
10 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
22.87
30.07
37.97
32.51
27.25
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. Uses both hands and both legs equally well? Yes NO
Comments:
2. Feet are flat on the surface most of the time? Yes NO
Comments:
3. Concerns about not making sounds? YES No
Comments:
4. Family history of hearing impairment? YES No
Comments:
5. Concerns about vision? YES No
Comments:
6. Any medical problems? YES No
Comments:
7. Concerns about behavior? YES No
Comments:
8. Other concerns? YES No
Comments:
