24 Month Questionnaire
Child's Information
- Child’s first name: Luke
- Child’s date of birth: 2/23/13
- Child's ID #: 13235457679891384
- Person filling out questionnaire: Lucy Jones
- Address: 20 First Street, Baltimore, MD, 21230, United States
- Relationship to child: Mother
Program Information
- Program name: Charm City Child Care
- Program ID #: 243465687819213
Questions about behaviors children may have
Below are questions regarding your child’s behavior. Please read each question carefully and check the box that best describes your child’s behavior. Also, check the circle if the behavior is a concern.
Important Points to Remember:
- Answer questions based on your child’s usual behavior, not behavior when your child is sick, very tired, or hungry.
- Caregivers should complete ASQ:SE-2.
Questionnaire Responses
| # | OFTEN OR ALWAYS | SOME TIMES | RARELY OR NEVER | CHECK IF THIS IS A CONCERN |
|---|---|---|---|---|
| 9. Does your child stiffen and arch his back when picked up? | □ | □ | ■ | ○ |
| 10. Is your child interested in things around her, such as people, toys, and foods? | ■ | □ | □ | ○ |
| 11. Does your child cry, scream, or have tantrums for long periods of time? | □ | ■ | □ | ○ |
| 12. Do you and your child enjoy mealtimes together? | ■ | □ | □ | ○ |
| 13. Does your child have eating problems? | □ | □ | ■ | ○ |
| 14. Does your child sleep at least 10 hours in a 24-hour period? | ■ | □ | □ | ○ |
| 15. When you point at something, does your child look in the direction you are pointing? | ■ | □ | □ | ○ |
| 16. Does your child have trouble falling asleep at naptime or at night? | □ | □ | ■ | ○ |
| 17. Does your child get constipated or have diarrhea? | □ | □ | ■ | ○ |
Observations
- TOTAL POINTS ON PAGE: 5
Further Questions
| # | OFTEN OR ALWAYS | SOME TIMES | RARELY OR NEVER | CHECK IF THIS IS A CONCERN |
|---|---|---|---|---|
| 18. Does your child follow simple directions? | ☐ | ☐ | ☐ | ○ |
| 19. Does your child let you know how he is feeling? | ☐ | ☐ | ☐ | ○ |
| 20. Does your child check to make sure you are near when exploring? | ☐ | ☐ | ☐ | ○ |
| 21. Does your child do things over and over? | ☐ | ☐ | ☐ | ○ |
| 22. Does your child like to hear stories or sing songs? | ☐ | ☐ | ☐ | ○ |
| 23. Does your child hurt himself on purpose? | ☐ | ☐ | ☐ | ○ |
| 24. Does your child like to be around other children? | ☐ | ☐ | ☐ | ○ |
| 25. Does your child try to hurt others? | ☐ | ☐ | ☐ | ○ |
| 26. Does your child try to show you things? | ☐ | ☐ | ☐ | ○ |
- TOTAL POINTS ON PAGE: 0
Concerns and Comments
- Concerns about eating or sleeping: No
- Other worries: Luke's reaction to being in new situations concerns us because he gets very upset and cries for a long time.
- What do you enjoy about your child? When Luke is happy and comfortable, his smile and laughter make everyone around him smile.
ASQ:SE-2 Scoring Chart:
- Score items (Z = 0, V = 5, X = 10, Concern = 5).
- TOTAL POINTS: 40
Overall Responses and Concerns:
- Any concerns marked on scored items? YES
- Eating/sleeping concerns? YES
- Comments: Adapting to new situations
Follow-up Referral Considerations
- No developmental or health factors noted.
- Family concerns have been expressed.