ASQ-3 12-months 英文

Ages&StagesQuestionnaires®,ThirdEdition(ASQ-3™),Squires&Bricker©2009PaulH.BrookesPublishingCo.Allrightsreserved.P101120100PersonfillingoutquestionnaireBaby’sinformationDateASQcompleted:Relationshiptobaby:ParentStreetaddress:Namesofpeopleassistinginquestionnairecompletion:GrandparentorotherrelativeGuardianFosterparentTeacherChildcareproviderOther:Ages&StagesQuestionnaires®MonthQuestionnaire11months0daysthrough12months30daysPleaseprovidethefollowinginformation.Useblackorblueinkonlyandprintlegiblywhencompletingthisform.12Baby’sfirstname:Baby’slastname:Baby’sdateofbirth:Firstname:Lastname:Middleinitial:City:Hometelephonenumber:State/Province:ZIP/Postalcode:Othertelephonenumber:E-mailaddress:Ifbabywasborn3ormoreweeksprematurely,#ofweekspremature:Baby’sgender:MaleFemaleMiddleinitial:Country:ProgramInformationAgeatadministrationinmonthsanddays:BabyID#:ProgramID#:Programname:Ifpremature,adjustedageinmonthsanddays:Ages&StagesQuestionnaires®,ThirdEdition(ASQ-3™),Squires&Bricker©2009PaulH.BrookesPublishingCo.Allrightsreserved.page2of6E101120200MonthQuestionnaire1211months0daysthrough12months30daysImportantPointstoRemember:❑✓Tryeachactivitywithyourbabybeforemarkingaresponse.❑✓Makecompletingthisquestionnaireagamethatisfunforyouandyourbaby.❑✓Makesureyourbabyisrestedandfed.❑✓Pleasereturnthisquestionnaireby_______________.Notes:________________________________________________________________________________________________________________________________________________________________________________Onthefollowingpagesarequestionsaboutactivitiesbabiesmaydo.Yourbabymayhavealreadydonesomeoftheactivitiesdescribedhere,andtheremaybesomeyourbabyhasnotbegundoingyet.Foreachitem,pleasefillinthecirclethatindi-cateswhetheryourbabyisdoingtheactivityregularly,sometimes,ornotyet.COMMUNICATION1.Doesyourbabymaketwosimilarsounds,suchas“ba-ba,”“da-da,”or“ga-ga”?(Thesoundsdonotneedtomeananything.)2.Ifyouaskyourbabyto,doesheplayatleastonenurserygameevenifyoudon’tshowhimtheactivityyourself(suchas“bye-bye,”“Peeka-boo,”“clapyourhands,”“SoBig”)?3.Doesyourbabyfollowonesimplecommand,suchas“Comehere,”“Giveittome,”or“Putitback,”withoutyourusinggestures?4.Doesyourbabysaythreewords,suchas“Mama,”“Dada,”and“Baba”?(A“word”isasoundorsoundsyourbabysaysconsistentlytomeansomeoneorsomething.)5.Whenyouask,“Whereistheball(hat,shoe,etc.)?”doesyourbabylookattheobject?(Makesuretheobjectispresent.Mark“yes”ifsheknowsoneobject.)6.Whenyourbabywantssomething,doeshetellyoubypointingtoit?GROSSMOTOR1.Whileholdingontofurniture,doesyourbabybenddownandpickupatoyfromthefloorandthenreturntoastandingposition?2.Whileholdingontofurniture,doesyourbabylowerherselfwithcontrol(withoutfallingorfloppingdown)?3.Doesyourbabywalkbesidefurniturewhileholdingonwithonlyonehand?YESSOMETIMESNOTYETCOMMUNICATIONTOTALYESSOMETIMESNOTYET4.Ifyouholdbothhandsjusttobalanceyourbaby,doeshetakeseveralstepswithouttrippingorfalling?(Ifyourbabyalreadywalksalone,mark“yes”forthisitem.)5.Whenyouholdonehandjusttobalanceyourbaby,doesshetakeseveralstepsforward?(Ifyourbabyalreadywalksalone,mark“yes”forthisitem.)6.Doesyourbabystandupinthemiddleofthefloorbyhimselfandtakeseveralstepsforward?FINEMOTOR1.Afteroneortwotries,doesyourbabypickupapieceofstringwithhisfirstfingerandthumb?(Thestringmaybeattachedtoatoy.)2.DoesyourbabypickupacrumborCheeriowiththetipsofherthumbandafinger?Shemayrestherarmorhandonthetablewhiledoingit.3.Doesyourbabyputasmalltoydown,withoutdroppingit,andthentakehishandoffthetoy?4.Withoutrestingherarmorhandonthetable,doesyourbabypickupacrumborCheeriowiththetipsofherthumbandafinger?5.Doesyourbabythrowasmallballwithaforwardarmmotion?(Ifhesimplydropstheball,mark“notyet”forthisitem.)6.Doesyourbabyhelpturnthepagesofabook?(Youmayliftapageforhimtograsp.)Ages&StagesQuestionnaires®,ThirdEdition(ASQ-3™),Squires&Bricker©2009PaulH.BrookesPublishingCo.Allrightsreserved.12MonthQuestionnairepage3of6E101120300YESSOMETIMESNOTYETGROSSMOTORTOTALYESSOMETIMESNOTYETFINEMOTORTOTAL*IfFineMotorItem4ismarked“yes”or“sometimes,”markFineMotorItem2“yes.”*GROSSMOTOR(continued)PROBLEMSOLVING1.Whenholdingasmalltoyineachhand,doesyourbabyclapthetoystogether(like“Pat-a-cake”)?2.DoesyourbabypokeatortrytogetacrumborCheeriothatisinsideaclearbottle(suchasaplasticsoda-popbottleorbabybottle)?3.Afterwatchingyouhideasmalltoyunderapieceofpaperorcloth,doesyourbabyfindit?(Besurethetoyiscompletelyhidden.)4.Ifyouputasmalltoyintoabowlorbox,doesyourbabycopyyoubyputtinginatoy,althoughshemaynotletgoofit?(Ifshealreadyletsgoofthetoyintoabowlorbox,mark“yes”forthisitem.)5.Doesyourbabydroptwosmalltoys,oneaftertheother,intoacontainerlikeabowlorbox?(Youmayshowhimhowtodoit.)6.Afteryouscribblebackandforthonpaperwithacrayon(orapencilorpen),doesyourbabycopyyoubyscribbling?(Ifshealreadyscribblesonherown,mark“yes”forthisitem.)PERSONAL-SOCIAL1.Whenyouholdoutyourhandandaskforhistoy,doesyourbabyofferittoyouevenifhedoesn’tletgoofit?(Ifhealreadyletsgoofthetoyintoyourhand,mark“yes”forthisitem.)2.Whenyoudressyourbaby,doesshepushherarmthroughasleeveonceherarmisstartedinthehol