5 YEAR OLD ASQ:SE QUESTIONNAIRE

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 { X } Sometime { Y} Rarely or never { Z }

Does your child look at you when you talk to him :

x
y
z
Others

Does your child like to be hugged or cuddeed?

x
y
z
Others

Does your child cling to you more than you expect?

x
y
z
Others

Does your child greet or say hello to familiar or adults?

x
y
z
Others

Does your child seem happy?

x
y
z
Others

Does your child like to hear stories and sing songs?

x
y
z
Others

Does your child to go bathroom by herself? (reminder and help with wiping are okay.)

x
y
z
Others

Does your child seem to friendly with strangers?

x
y
z
Others

Does your child seem more active than other children her age?

x
y
z
Others

Can your child settle himself down after periods of exciting activity?

x
y
z
Others

Does your child cry, scream, or have tantrums for long period of time?

x
y
z
Others

Does your child do thing over and over and can't seem to stop? Examples are rocking, hand flapping, spinning .

x
y
z
Others

Can your child stay with activities she enjoys for at least 15 minutes (not including watching television)?

x
y
z
Others

Does your child do what you ask him to do?

x
y
z
Others

Is your child interested in things around her, such as people, toys and food?

x
y
z
Others

When upset, can your child calm down within 15 minutes?

x
y
z
Others

Does your child have eating problems, such as stuffing foods, vomiting, eating nonfood items?

x
y
z
Others

Do and your child enjoy mealtimes together?

x
y
z
Others

When you point at something , does your child look in the direction you are pointing?

x
y
z
Others

Does your child sleep at least 8 hours in a 24 hours period?

x
y
z
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?

x
y
z
Others

Does your child follow routine directions? For example, Does she came to the table or help clean up her toys when asked?

x
y
z
Others

Does your child check to make sure you are near when exploring new places, such as a park or a friend's home?

x
y
z
Others

Can your child move from one activity to the next with little difficulty, such as from playtime to mealtime?

x
y
z
Others

Does your child stay away from dangerous things, such as fire and moving cars?

x
y
z
Others

Does your child use words to describe his feelings of others, such as, "I' am happy." "I don't like it" or "she is sad" ?

x
y
z
Others

Does your child destroy or damage things on purpose?

x
y
z
Others

Does your child hurt himself on purpose?

x
y
z
Others

Does your child play alongside other children?

x
y
z
Others

Does your child show an interest in or knowledge of sexual language and activity ?

x
y
z
Others

Does your child try to hurt other children's, adults or animals (for example, by kicking or biting)?

x
y
z
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?

5 years old form