30 MONTH ASQ:SE QUESTIONNAIRE

info@littlegeneration.com 419-724-7920

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( For Children Ages 30 Through 36 Months )

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2 years old form

Child Name :
Child Date Of Birth :
Todays Date :
Person filling out this questionnaire :
What is your Relation Ship to the Child :
Your Telephone :
Your Mailing Address
CIty :
State :
Zip :
LIst of people Questionnaire Completion :
Administering Programe or Provider :
Please Read each question carefully and
1 : check the box ❏ the best describe your child behavior.
2 : check the OTHER if this behavior is concern.

Most of the Time { Z } Sometime { V } Rarely or never { X }
Does your child look at you when you talk to him :
- z
- v
- x
- Others
Does your child like to be hugged or cuddeed?
- z
- v
- x
- Others
Does your child cling to you more than you expect?
- z
- v
- x
- Others
Does your child greet or say hello to familiar or adults?
- z
- v
- x
- Others
Does your child seem happy?
- z
- v
- x
- Others
Does your child like to hear stories and sing songs?
- z
- v
- x
- Others
Does your child seem to friendly with strangers?
- z
- v
- x
- Others
Does your child seem more active than other children her age?
- z
- v
- x
- Others
Can your child settle himself down after periods of exciting activity?
- z
- v
- x
- Others
Does your child cry, scream, or have tantrums for long period of time?
- z
- v
- x
- Others
Does your child do thing over and over and can't seem to stop? Examples are rocking, hand flapping, spinning .
- z
- v
- x
- Others
Can your child stay with activities she enjoys for at least 3 minutes (not including watching television)?
- z
- v
- x
- Others
Does your child do what you ask him to do?
- z
- v
- x
- Others
Is your child interested in things around her, such as people, toys and food?
- z
- v
- x
- Others
When upset, can your child calm down within 15 minutes?
- z
- v
- x
- Others
Does your child have eating problems, such as stuffing foods, vomiting, eating nonfood items?
- z
- v
- x
- Others
Do and your child enjoy mealtimes together?
- z
- v
- x
- Others
When you point at something , does your child look in the direction you are pointing?
- z
- v
- x
- Others
Does your child sleep at least 8 hours in a 24 hours period?
- z
- v
- x
- Others
Does your child let you know how he is feeling with either words or gestures? For example, Does he let you know when he is hungry, hurt or tired?
- z
- v
- x
- Others
Does your child follow routine directions? For example, Does she came to the table or help clean up her toys when asked?
- z
- v
- x
- Others
Does your child check to make sure you are near when exploring new places, such as a park or a friend's home?
- z
- v
- x
- Others
Can your child move from one activity to the next with little difficulty, such as from playtime to mealtime?
- z
- v
- x
- Others
Does your child stay away from dangerous things, such as fire and moving cars?
- z
- v
- x
- Others
Does your child destroy or damage things on purpose?
- z
- v
- x
- Others
Does your child hurt himself on purpose?
- z
- v
- x
- Others
Does your child play alongside other children?
- z
- v
- x
- Others
Does your child try to hurt other children's, adults or animals (for example, by kicking or biting)?
- z
- v
- x
- Others
Has anyone expressed concern about your child behavior ? please explain :
Do you have concern about your chikld's eaitng and sleeping Beauvoir or her toilet training? if so, please explain :
Is there anything that worries you about your child? if so, please explain :
What thing do you enjoy most about your child?