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4 YEAR OLD ASQ:SE QUESTIONNAIRE
( For Children Age 4 )
4 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 { 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 cling to you more than you expect?
x
y
z
Others
Does your child talk and/or play with adults she knows well?
x
y
z
Others
Does your child greet or say hello to familiar or adults?
x
y
z
Others
Does your child stay dry during the day?
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 10 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 destroy or damage things on purpose?
x
y
z
Others
Does your child hurt himself on purpose?
x
y
z
Others
Does your child follow the rules? (at home, at child care)
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
Does your child show an interest in or knowledge of sexual language and activity ?
x
y
z
Others
Has anyone expressed concern about your child behavior ? please explain :
Do you have concern about your child's eating 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?