squiresASQ_16mo_pg1

Ages & Stages® Questionnaires

16 Month Questionnaire

Please provide the following information. Use black or blue ink only and print legibly when completing this form.
Date ASQ completed: 9/20/2008

Child’s Information

Child’s first name: Annie Roberts
Child’s date of birth: 5/5/2007
If child was born 3 or more weeks prematurely, # of weeks premature:
Street address: 33 Main Street
City: Jonestown
State/Province: SAMPLE
Country: USA
ZIP/Postal code: 61924

Program Information

Program name: Jonestown Child Care Center
Child ID #: 36759111023412358

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 child.
Make sure your child is rested and fed.

COMMUNICATION

YES	SOMETIMES	NOT YET
1. Does your child point to, pat, or try to pick up pictures in a book?	10
2. Does your child say four or more words in addition to “Mama” and “Dada”?	10
3. When your child wants something, does she tell you by pointing to it?	10
4. When you ask your child to, does he go into another room to find a familiar toy or object?	10
5. Does your child imitate a two-word sentence?	10
6. Does your child say eight or more words in addition to “Mama” and “Dada”?	5

COMMUNICATION TOTAL 55

GROSS MOTOR

YES	SOMETIMES	NOT YET
1. Does your child stand up in the middle of the floor by himself and take several steps forward?	10
2. Does your child climb onto furniture or other large objects?	5
3. Does your child bend over or squat to pick up an object from the floor?	10
4. Does your child move around by walking, rather than crawling on her hands and knees?	●	○
5. Does your child walk well and seldom fall?	○	●
6. Does your child climb on an object to reach something he wants?	○	○
GROSS MOTOR TOTAL 40

FINE MOTOR

YES	SOMETIMES	NOT YET
1. Does your child help turn the pages of a book?	○	●
2. Does your child throw a small ball with a forward arm motion?	●	○
3. Does your child stack a small block or toy on top of another one?	●	○
4. Does your child stack three small blocks or toys on top of each other by herself?	●	○
5. Does your child make a mark on the paper with a crayon?	○	●
6. Does your child turn the pages of a book by himself?	○	○
FINE MOTOR TOTAL 40

PROBLEM SOLVING

YES	SOMETIMES	NOT YET
1. After you scribble on paper with a crayon, does your child copy you by scribbling?	○	●
2. Can your child drop a crumb into a small, clear bottle?	○	●
3. Does your child drop several small toys into a container?	●	○

PROBLEM SOLVING TOTAL 45

PERSONAL-SOCIAL

YES	SOMETIMES	NOT YET
1. Does your child feed himself with a spoon?	●	○
2. Does your child come to you when she needs help?	●	●
3. Does your child play with a doll or stuffed animal?	●	○
4. While looking at himself in the mirror, does your child offer a toy to his own image?	●	○
PERSONAL-SOCIAL TOTAL 50

OVERALL Comments:

Do you think your child hears well?
Do you think your child talks like other toddlers his age?
Can you understand most of what your child says?
Has your child had any medical problems in the last several months?

ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR 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.

Area	Cutoff	Total Score
Communication	16.81	55
Gross Motor	37.91	40
Fine Motor	31.98	40
Problem Solving	30.51	45
Personal-Social	26.43	50