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Month Questionnaire. Please provide the following information. Use black or blue ink only and print legibly when completing this form. Date ASQ completed: Baby’s information. Baby’s first name: Middle initial: Baby’s last name: If baby was born 3 or more weeks prematurely, # of. Baby’s gender:
Use black or blue ink only and print legibly when completing this form. Date ASQ completed: Child’s information. Child’s first name: Middle initial: Child’s last name: If child was born 3 or more weeks prematurely, # of. Child’s gender: Male. Female.
Count as “yes”. 2. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single Count as “not yet” line in a vertical direction? 3.
Count as “yes”. 5. After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark “not yet” if your Count as “not yet” child scribbles back and forth.) 6.
There are 21 ASQ-3 questionnaires for use with children from 1 month to 5½ years old (one questionnaire for each age range). Here are the five important areas of development that each questionnaire looks at: Communication: Your child’s language skills, both what your child understands and what he or she can say.
Tell me more about ASQ:SE-2 3 ASQ:SE-2 is a set of questionnaires with a deep, exclusive focus on social-emotional develop-ment. There are 9 ASQ:SE-2 questionnaires for use with children from 1 month to 6 years old.
Use black or blue ink only and print legibly when completing this form. Date ASQ completed: Child’s information. Child’s first name: Middle initial: Child’s last name: If child was born 3 or more weeks prematurely, # of. Child’s gender: Male. Female.
