48-month Assessment - Young Minds In Motion

CUESTIONARIO PARA PADRES
Queridos padres,

Ayúdenos a conocer a su hijo por llenando este formulario. Todas la información será confidencial. Nosotros será Use lo que nos dice a medida que comenzamos a conocer a su hijo y pagslunnorte Washingtonys to metroeet Holas/her nortemimires y To hmilpags hyometro/ her desarrollar. Por favor regreso eso a colegio como pronto como posible.

¡Muchas gracias!
El nombre del niño
Apodo del niño
Padres Nombres
Fecha
MM barra DD barra AAAA
Maestro del niño
¿Vive con su hijo?
- Ambos padres
- Monoparental
- Otros adultos
Por favor especifica
Enumere los nombres y edades de otras personas que viven en su hogar. (Esto me ayudará a escribir los nombres correctamente en las imágenes que su hijo dibuje sobre su familia).
Mascotas (nombre y tipo de animal)
Trabajo del padre
Profesión de la madre
¿Tiene su hijo una habitación propia?
- si
- No
Si no es así, ¿con quién comparte habitación?
¿Cuáles son las actividades e intereses de juego favoritos de su hijo?
¿El niño usa palabras especiales para ir al baño?
Programas de televisión favoritos del niño
Horas diarias dedicadas a ver televisión
¿Suele jugar su hijo?
- ¿Solo?
- ¿Con un amigo?
- ¿Con algunos amigos?
- con niños más pequeños?
- con niños mayores?
- con niños de la misma edad?
¿Tiene el niño miedos decididos? ¿Entonces qué?
¿Qué responsabilidades tiene su hijo en casa?
¿Cuál es tu mayor problema de disciplina?
¿Cuál es el cuento, tipo de cuento o libro favorito de su hijo?
¿Tuvo su hijo un parto prematuro o difícil que pueda indicar retrasos cognitivos?
¿Es el inglés el idioma principal que se habla en el hogar? Si no es así, ¿qué es?
¿Su hijo habla inglés? ¿Entender inglés?
¿Cómo se siente su hijo al venir a la escuela?
¿Qué espera que su hijo aprenda este año?
Haga comentarios sobre cualquier otra cosa que crea que necesito saber sobre su hijo.
Nuestro objetivo es fomentar un sentido de pertenencia, promover el aprecio por los demás y enriquecer las experiencias de los niños al integrar en nuestro plan de estudios actividades e información que reflejen los antecedentes individuales de nuestros niños. One way we can do this is by learning about each child?s family background, celebrated holidays, and traditions. Please take a few minutes to share with us your special family days or activities and how they are carried out in your home.
¿Qué idiomas además del inglés hablan los miembros de la familia que rodean a su hijo?
¿Su hijo tiene alguna discapacidad física o de aprendizaje? Si es así, describa
Are there any family members with disabilities that may directly impact your child?s daily life (for example, a deaf grandparent, wheelchair bound parent, etc.)?
What information about your family?s background and culture would you like to share with us?
¿Cuáles son las fiestas, los días especiales o las tradiciones en las que participa su familia?
¿Hay alimentos, canciones, elementos o símbolos especiales que incluya en su celebración de momentos familiares especiales?
¿Tiene su hijo alguna restricción dietética debido a alergias, intolerancias, preferencias familiares o religiosas? Si es así, ¿qué está restringido?
Are there any activities from your family?s culture or traditions that you would like to share with your child?s classroom?
Are there any activities from your family?s culture or traditions that you would like to share with your child?s classroom?
Haga comentarios sobre cualquier otra cosa que crea que necesito saber sobre su hijo.
¿Cuáles son sus puntos fuertes?
¿Cuáles son las áreas de debilidad? ¿En qué te gustaría que tu hijo mejorara?
My child learns best when the teacher is?.
My child does not work well with?
¿Cuál es la mejor forma de motivar a su hijo?
¿Qué esperas en YMIM?
How would you like to be involved with your child?s education?
What is your preferred method of communication (email, phone call, meeting, note?)___
Date ASQ Completed:
DD barra MM barra AAAA
Child?s date of birth:
MM barra DD barra AAAA
¿Es un chico o una chica?
- Niño
- Niña
Person filling out Questionnaire
First Name
Middle Initial
Last Name
Street Address
Relacion hacía el niño:
- Parent
- Guardian
- Teacher
- Child Care Provider
- Grandparent or other relative
- Foster Parent
City :
State / Province:
Zip / Postal Code:
Country
Home telephone number:
Other telephone number:
Email Address
Name of the people assisting in questionnaire completion:
Program Information
Child ID #
Program ID #
Program Name
Puntos importantes para recordar:
- Pruebe cada actividad con su hijo antes de marcar una respuesta.
- Haga que completar este cuestionario sea un juego divertido para usted y su hijo.
- Asegúrese de que su hijo no esté cansado ni tenga hambre.
- Please return this questionnaire by ________________________
Notes
1. Does your child name at least three items from a common category? For example, if you say to your child, ?Tell me some things that you can eat,? does your child answer with something like ?cookies, eggs, and cereal?? Or if you say, ?Tell me the names of some animals,? does your child answer with something like ?cow, dog, and elephant??
- si
- A veces
- Aún no
2. Does your child answer the following questions? (Mark ?sometimes? if your child answers only one question.)
- si
- A veces
- Aún no
?What do you do when you are hungry?? (Acceptable answers include ?get food,? ?eat,? ?ask for something to eat,? and ?have a snack.?) Please write your child?s response:
?What do you do when you are tired?? (Acceptable answers include ?take a nap,? ?rest,? ?go to sleep,? ?go to bed,? ?lie down,? and ?sit down.?) Please write your child?s response:
3. Does your child tell you at least two things about common objects? For example, if you say to your child, ?Tell me about your ball,? does she say something like, ?It?s round. I throw it. It?s big??
- si
- A veces
- Aún no
4. Does your child use endings of words, such as ?-s,? ?-ed,? and ?-ing?? For example, does your child say things like, ?I see two cats,? ?I am playing,? or ?I kicked the ball??
- si
- A veces
- Aún no
Comunicación

( Continued )
5. Without your giving help by pointing or repeating, does your child fol- low three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, ?Clap your hands, walk to the door, and sit down,? or ?Give me the pen, open the book, and stand up.?
- si
- A veces
- Aún no
6. Does your child use all of the words in a sentence (for example, ?a,? ?the,? ?am,? ?is,? and ?are?) to make complete sentences, such as ?I am going to the park,? or ?Is there a toy to play with?? or ?Are you coming, too??
- si
- A veces
- Aún no
Total de comunicación
MOTOR BRUTO
1. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)
- si
- A veces
- Aún no
2. Does your child climb the rungs of a ladder of a playground slide and slide down without help?
- si
- A veces
- Aún no
3. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as ?not yet.?)
- si
- A veces
- Aún no
4. Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?
- si
- A veces
- Aún no
5. Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together?
- si
- A veces
- Aún no
6. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)
- si
- A veces
- Aún no
Gross Motar Total
Fine Motor
1. Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)
- si
- A veces
- Aún no
2. Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child?s use of scissors for safety reasons.)
- si
- A veces
- Aún no
3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child?s drawings should look similar to the design of the shapes below, but they may be different in size.)
- si
- A veces
- Aún no
4. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll?s clothing.)
- si
- A veces
- Aún no
5. Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?
- si
- A veces
- Aún no
6. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.)
- si
- A veces
- Aún no
Fine Motor Total
Problem Solving
1. When you say, ?Say ?five eight three,?? does your child repeat just the three numbers in the same order? Do not repeat the numbers. If neces- sary, try another series of numbers and say, ?Say ?six nine two.?? (Your child must repeat just one series of three numbers to answer ?yes? to this question.)
- si
- A veces
- Aún no
2. When asked, ?Which circle is the smallest?? does your child point to the smallest circle? (Ask this question withoutproviding help by point- ing, gesturing, or looking at the smallest circle.)
- si
- A veces
- Aún no
3. Without your giving help by pointing, does your child follow three dif- ferent directions using the words ?under,? ?between,? and ?middle?? For example, ask your child to put the shoe ?under the couch.? Then ask her to put the ball ?between the chairs? and the book ?in the middle of the table.?
- si
- A veces
- Aún no
4. When shown objects and asked, ?What color is this?? does your child name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark ?yes? only if your child answers the question correctly using five colors.)
- si
- A veces
- Aún no
5. Does your child dress up and ?play-act,? pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.
- si
- A veces
- Aún no
6. If you place five objects in front of your child, can he count them by saying, ?one, two, three, four, five,? in order? (Ask this question without providing help by pointing, gesturing, or naming.)
- si
- A veces
- Aún no
Personal Social
1. Does your child serve herself, taking food from one container to an- other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?
- si
- A veces
- Aún no
1. Does your child serve herself, taking food from one container to an- other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?
- si
- A veces
- Aún no
2. Does your child tell you at least four of the following? Please mark the items your child knows.
- a. First name
- b. Age
- c. City she lives in
- d. Last Name
- e. Boy or Girl
- f. Telephone Number
3. Does your child wash his hands using soap and water and dry off with a towel without help?
- si
- A veces
- Aún no
4. Does your child tell you the names of two or more playmates, not in- cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)
- si
- A veces
- Aún no
5. Does your child brush her teeth by putting toothpaste on the tooth- brush and brushing all of her teeth without help? (You may still need to check and rebrush your child?s teeth.)
- si
- A veces
- Aún no
6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?
- si
- A veces
- Aún no
Personal Social Total
Overall

Parents and providers may use the space below for comments.
1. Do you think your child hears well? If no, explain:
2. Do you think your child talks like other children her age? If no, explain:
3. Can you understand most of what your child says? If no, explain:
4. Can other people understand most of what your child says? If no, explain:
5. Do you think your child walks, runs, and climbs like other children his age? If no, explain:
6. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:
7. Do you have any concerns about your child?s vision? If yes, explain:
8. Has your child had any medical problems in the last several months? If yes, explain:
9. Do you have any concerns about your child?s behavior? If yes, explain:
10. Does anything about your child worry you? If yes, explain:
1. SCORE AND TRANSFER TOTALS TO CHART BELOW:

See ASQ-3 User?s Guide for details, including how to adjust scores if item responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total. In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.

Areas
Communication " Cutt Off: 30.72 "
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 60
Gross Motor " Cutt Off: 32.78 "
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 60
Fine Motor " Cutt Off: 15.81 "
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 60
Problem Solving " Cutt Off: 31.30 "
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 60
Personal Solcial " Cutt Off: 26.60 "
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 60
1. Hears well?
- si
- No
2. Talks like other children his age?
- si
- No
3. Understand most of what your child says ?
- si
- No
4. Others understand most of what your child says?
- si
- No
5. Walks, runs, and climbs like other children?
- si
- No
6. Family history of hearing impairment?
- si
- No
7. Concerns about vision?
- si
- No
8. Any medical problems?
- si
- No
9. Concerns about behavior?
- si
- No
9. Concerns about behavior?
- si
- No
10 Other concerns?
- si
- No
ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP

You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine the appropriate follow-up.
If the child?s total score is above 40 it is above the cutoff and the child?s development appears to be on schedule.
If the child?s total score is above 15, but less than 40 it is above the cutoff and the child?s development appears to be on schedule.
If the child?s total score is below 15, it is below the cutoff. Further assessment with a professional may be needed.
4.FOLLOW-UP ACTION TAKEN:
Fill all that apply
Provide activities and rescreen in ________ months.
Share results with primary health care provider
- si
- No
Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
- si
- No
Refer to primary health care provider or other community agency (specify reason):
Refer to early intervention/early childhood special education.
- si
- No
No further action taken at this time
- si
- No
Other (specify):

Evaluación de 48 meses

CUESTIONARIO PARA PADRES

Person filling out Questionnaire

Program Information

Puntos importantes para recordar:

Comunicación

( Continued )

MOTOR BRUTO

Fine Motor

Problem Solving

Personal Social

Overall

1. SCORE AND TRANSFER TOTALS TO CHART BELOW:

Areas

ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP

4.FOLLOW-UP ACTION TAKEN: