12 Month Asq Se
Please note that this tool is proprietary and may only be obtained by contacting the creators of the tool below. However, there is a score summary form available for use in ETO.
- Does it take longer than 30 minutes to feed your baby? Do you and your baby enjoy mealtimes together? Does your baby have any eating problems, such as gagging, vomiting, or ? (You may write in another problem.) 15. Does your baby have trouble falling asleep at. 12 Month ASQ:SE.
- Now in a new second edition, the 9 age-appropriate questionnaires (2, 6, 12, 18, 24, 30, 36, 48, and 60 months) effectively screen 7 key social-emotional areas: self-regulation, compliance, adaptive functioning, autonomy, affect, social-communication, and interaction with people.
The ASQ-SE helps identify 'young children at risk for social or emotional difficulties, identify behaviors of concern to caregivers, and identify any need for further assessment.' It screens in the areas of 'self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people.' The assessment tool is available in 8 versions to allow assessment at: 6, 12, 18, 24, 30, 36, 48, and 60 months of age. The web-site provides an age calculator to assist in choosing the right tool by factoring in weeks born premature: http://agesandstages.com/age-calculator/
12 Month ASQ:SE Questionnaire (For children ages 9 through 14 months). Does it take longer than 30 minutes to feed your baby? Do you and your baby enjoy.
The tool can be administered electronically or through paper and pencil, and is written at the 6th grade reading level to make it easier for parents to understand. Completing the questionnaire takes about 10-15 minutes, and involves parents observing the behavior of their children.
The availability of the tool at various age levels allows the developmental progress of the children to be tracked over time.
The tool can be purchased at: Ages and Stages Questionnaire
All new patients through 60 months of age are required to complete Ages & Stages Questionnaire (ASQ-3). Please print and complete age appropriate forms, available below for your convenience. All scoring will be done for you at the office, at time of visit.
Please note that patients in 18 months and 24 months age groups will also need to complete M-Chat questionnaire, link to which can be found next to the corresponding ASQ-3 form.
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Kindly keep in mind that age of premature babies up to 24 months counts differently. To avoid confusion, and for your convenience, please use this quick ASQ Age Calculator to ensure correct ASQ-3 questionnaire is chosen for your child’s age.
Printable Questionnaire Forms
Asq Se 24 Months Scoring Sheet
| Child's Age | English | Spanish |
|---|---|---|
| 1 month 0 days through 2 month 30 days | 2 month | 2 month |
| 3 months 0 days through 4 months 30 days | 4 month | 4 month |
| 5 months 0 days through 6 months 30 days | 6 month | 6 month |
| 7 months 0 days through 8 months 30 days | 8 month | 8 month |
| 9 months 0 days through 9 months 30 days | 9 or 10 month | 9 or 10 month |
| 10 months 0 days through 10 months 30 days | 10 month | 10 month |
| 11 months 0 days through 12 months 30 days | 12 month | 12 month |
| 13 months 0 days through 14 months 30 days | 14 month | 14 month |
| 15 months 0 days through 16 months 30 days | 16 month | 16 month |
| 17 months 0 days through 18 months 30 days | 18 month + M-CHAT | 18 month + M-CHAT |
| 19 months 0 days through 20 months 30 days | 20 month | 20 month |
| 21 months 0 days through 22 months 30 days | 22 month | 22 month |
| 23 months 0 days through 25 months 15 days | 24 month + M-CHAT | 24 month + M-CHAT |
| 25 months 16 days through 28 months 15 days | 27 month | 27 month |
| 28 months 16 days through 31 months 15 days | 30 month | 30 month |
| 31 months 16 days through 34 months 15 days | 33 month | 33 month |
| 34 months 16 days through 38 months 30 days | 36 month | 36 month |
| 39 months 0 days through 44 months 30 days | 42 month | 42 month |
| 45 months 0 days through 50 months 30 days | 48 month | 48 month |
| 51 months 0 days through 56 months 30 days | 54 month | 54 month |
| 57 months 0 days through 66 months 0 days | 60 month | 60 month |