asq3 screening results by child SAMPLE.pdf
SAMPLE ASQ-3 SCREENING RESULTS, BY CHILD REPORT
| Child Name | Provider | Child ID | Child DOB | Interval (mo.) | Questionnaire Type | Screening Date | Screening Completed By | Communication Score | Communication Cutoff | Communication Results | Gross Motor Score | Gross Motor Cutoff | Gross Motor Results | Fine Motor Score | Fine Motor Cutoff | Fine Motor Results | Problem Solving Score | Problem Solving Cutoff | Problem Solving Results | Personal-Social Score | Personal-Social Cutoff | Personal-Social Results | Overall Concern | Overall No Concern |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Black, Fiona | Perkins, Amy | 2832938 | 11/10/2019 | 48 Month | ASQ-3 English | 9/13/2023 | Black, Pat (Mother) | 60 | 30.72 | Above | 40 | 32.78 | Monitoring | 50 | 15.81 | Above | 20 | 31.3 | Below | 60 | 26.6 | Above | 0 | 10 |
| Bollinger, Kelley | Perkins, Amy | 2746922 | 1/2/2019 | 54 Month | ASQ-3 English | 9/21/2023 | Bollinger, Eric (Father) | 50 | 31.85 | Above | 35 | 35.18 | Below | 50 | 17.32 | Above | 60 | 28.12 | Above | 50 | 32.33 | Above | 1 | 9 |
| Gonzalez, Chris | Perkins, Amy | 2746920 | 12/3/2018 | 60 Month | ASQ-3 English | 10/1/2023 | Gonzalez, Paul (Father) | 45 | 33.19 | Above | 60 | 31.28 | Above | 30 | 26.54 | Monitoring | 40 | 29.99 | Monitoring | 55 | 39.07 | Above | 0 | 10 |
| Truckenbrodt, Daniel | Perkins, Amy | 3231341 | 2/1/2020 | 42 Month | ASQ-3 Spanish | 9/15/2023 | Truckenbrodt, Daniel (Father) | 60 | 27.06 | Above | 60 | 36.27 | Above | 45 | 19.82 | Above | 60 | 28.11 | Above | 35 | 31.12 | Monitoring | 1 | 9 |